CB Boutique Microblading Form
Microblading is a procedure that can only be performed by a trained and qualified specialist using approved equipment to implant coloured pigments into the skin using sterile needles. The treatment requires your full consent and medical history disclosure so that your consultant can confirm you are a suitable candidate for the proposed treatment.
Your consultant will discuss the benefits and risks of the proposed treatment, and record the consultation on this form. This form will then be used for reference on subsequent visits.
It is essential that you discuss with the consultant any areas that you require further clarification to ensure that you are fully informed before a treatment commences.
Your consultant will discuss the procedure in full, including what it will involve, the healing process and further treatment where necessary. You will then be provided with written aftercare information for you to keep and refer to during the healing process.

PLEASE READ CAREFULLY – AND SIGN WHERE INDICATED, ONLY when you are happy to proceed.
Ensure all points below have been discussed with your consultant and you understand and accept these terms.
Terms of your treatment:
- You have chosen a cosmetic procedure that is not medically necessary.
- Microblading is an art process - not an exact science - and cannot guarantee an exact colour result due to how colours can heal differently in all individuals. The selected colour will be darker immediately after treatment. This darker colour should exfoliate and lighten within 7-14 days after treatment. Lighter colours fade faster than darker colours, and all colours can change with time.
- You may be required to return for additional treatments before your procedure is deemed complete. The payment for any additional work (if applicable) will be agreed prior to procedure commencing. Additional treatments cannot be performed for 4-8 weeks (depending on treatment) after initial procedure. This is in order to allow the initial treatment to heal fully.
- Your consultant will use a treatment plan to record the colours you have chosen, anaesthetic used, needles used and pre and post treatment photographs. This information will be held securely in your consultation record.
- The skin type of every client is different and colour should remain visible in the skin for several years (in some cases indefinitely). The pigment will be present permanently but not necessarily be visible. A re-touch procedure will be required periodically to keep the procedure looking fresh.
- After each treatment some swelling or redness may occur. In some cases there may be bruising. Your consultant will recommend solutions to reduce these symptoms. Throughout the treatment you may experience some discomfort, but your consultant will reassure you throughout and endeavour to make you feel comfortable.
- Pigments used in Semi Permanent Make Up contain iron oxides, and differ to the inks used in tattooing.
- You must adhere to aftercare instructions given to you after your treatment. This is very important and will ensure you aren’t vulnerable to infections after leaving the clinic. You must let the treated area heal properly. Avoid picking, plucking or knocking as this will hinder the healing process and could make the treatment appear uneven thus requiring further work.
- Be aware that skin altering procedures such as plastic surgery, implants and injectables may alter the Microblading look.

Your consultant will follow guidelines as outlined in section 15 of the Local Government Act 1982. In addition to this, it is recommended that trained consultants use aseptic conditions throughout the treatment.

First Name *
Your answer
Last Name *
Your answer
Mobile Phone Number *
Your answer
Home Address (including Postcode) *
Your answer
Email Address *
Your answer
Date of Birth *
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Occupation *
Your answer
Price agreed for today's treatment: *
Your answer
How did you hear about us?
Photographic Consent *
Required
Patch Test *
I understand that a skin patch test can determine whether I will suffer a reaction to the products used within 24 hours, but that it is inconclusive as to whether I will have an allergic reaction at any time in the future. I have taken a patch test prior to my initial treatment, and I therefore release CB Boutique from any liability related to an allergic reaction to the applied pigments or other products used after the procedure, or at a later date.
Required
Pigment Disclaimer *
Our Elite Microblading pigments comply with the requirements of ResAp (2008)1, the regulation dated 21 Dec. 2012 and the new pharmaceutical raw materials regulation dated 04/2013 concerning nickel content. Furthermore, each pigment is tested for contamination by an independent and accredited test laboratory. We guarantee that our pigments are produced using high-purity raw materials, are mixed in a vacuum, and are sterilised with gamma radiation.We do not add preservatives, as these may cause allergies. We only process pigments whose raw material quality according to ResAp (2008)1 is guaranteed. Elite Microblading pigments do not contain ferric oxides, dangerous AZO dyes, PAHs = polycyclic aromatic hydrocarbons, prohibited heavy metals, dangerous aromatic amines including NDELA = nitrosodiethanolamine. For more information please consult the safety data sheet.
Required
Consent *
I understand that my consultant will be in direct contact with me in relation to the microblading treatment. This treatment involves the use of disposable needles and that all other equipment is sterilised before use, all surfaces involved in the process are protected and that gloves will be worn at all times by the consultant during the treatment. The anaesthetic was obtained and applied by me. I hereby consent to receiving a microblading treatment. My consultant has explained the terms and conditions of the treatment and I have fully understood these. I hereby give written consent to the consultant who is a trained specialist, to carry out the treatment of my choice as requested by me on this consent and treatment agreement.
Required
This form was completed on (today's date): *
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Have you received any micropigmentation treatment before? *
If you answered "yes" to the above question, please provide the following information:
1. How long ago the treatment was? 2. What procedure you received? 3. At what clinic you received the treatment? 4. If you were happy with the result?
Your answer
Please confirm that you are over the age of 18: *
Required
Please confirm that you are not under the influence of drugs or alcohol: *
Required
Medical Conditions *
Yes
No
Do you feel fit, well, and able to have the microblading procedure today?
Do you have any allergies or have you experienced any allergic reactions to products such as latex gloves, etc.?
Are you currently taking any medication?
Do you have or are you planning to have any injectables, fillers or chemical peels?
Do you have any imminent holiday plans?
Do you suffer from epilepsy?
Do you knowingly suffer from any infectious diseases?
Do you suffer from a high or low blood pressure?
Do you suffer from diabetes?
Do you have any respiratory problems?
Do you suffer from, or have any problems with scars healing?
Do you suffer from dizziness or fainting attacks?
Do you suffer from HIV/AIDS?
Do you suffer from heart problems?
Do you suffer from Hepatitis?
Do you suffer from Haemophilia?
Do you suffer from skin problems (i.e. eczema, psoriasis)?
Do you have an allergy to penicillin?
Do you suffer from Keloid scarring?
Additional Information:
If you suffer from any of the above it is important that you notify your consultant who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health. Please provide any additional information below if you have ticked "yes" to any of the above medical conditions:
Your answer
Name and Address of GP *
Your answer
Are you pregnant, or trying to become pregnant? *
Do you currently have any metallic implants or a pacemaker? *
Medical Conditions Declaration *
I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medial history that it is my responsibility to inform my consultant.
Required
Terms and Conditions *
I confirm that the information I have provided on this form is true and correct. I accept that any treatment I have is taken at my own risk. I certify that I have read and have completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effects, for which I accept full liability/responsibility. I am aware that it is my responsibility to inform the Therapist of my current and ongoing medical or health conditions, as they may impact my suitability for certain treatments. I acknowledge the possible side effects of any beauty procedure, and understand that CB Boutique reserves the right to charge for appointments cancelled without 24 hours notice.
Treatment Plan
This section of the form is to be completed by the consultant, and must be stored together with the client's consent forms.
Full name of consultant: *
Your answer
Treatment being completed: *
Your answer
Treatment number: *
Required
For first visit only: Following consultation with your client, what is the agreed treatment and how many visits will it take to achieve?
Your answer
For 2nd and subsequent visits: CLIENT MUST COMPLETE A RE-CONSENT FORM.
Provide information on the following: 1. Were your clients expectations met? 2. Did the area heal as described? 3. Did they experience any issues? 4. What is the agreed objective for today’s procedure? 5. What is the predicted outcome and recommendations?
Your answer
Describe the treatment area including a description of the appearance of the skin: *
Your answer
What aftercare advice has been offered to the client and how was this advice given? *
Your answer
Consultant Declaration *
I, the consultant, confirm that I have checked all paperwork including consent forms and medical history, have discussed all procedure points with my client and they understand all elements. My client has participated fully in the choice of shape, placement and colour of their treatment.
Required
Client Declaration *
I, the client, agree with all points listed and discussed, and wish to proceed as recorded. I participated fully in the decision for the shape, placement, and colour selection of my micropigmentation treatment.
Required
Treatment Particulars *
Include Colour Used, Needles Used, and any Anaesthetic Used, including their Lots and Expiry Dates!
Your answer
Tolerance Level *
Your answer
Were any other people present? *
Your answer
Post-Treatment Client Declaration *
My procedure has been completed to my satisfaction and I have been given the opportunity to discuss any immediate concerns with my consultant. I understand my aftercare instructions.
Required
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