Medical History Intake Form

Have you or previously had any of the following?

Microblading - Client Consent Form

• You are over the age of sixteen and that you have truthfully represented to your technician that undergoing this procedure by your choice alone.

• You are not pregnant or nursing.

• You are not under the influence of alcohol or recreational drugs.

• You are not using blood thinner or medications that may increase your bleeding.

• You do not have skin conditions such as severe acne, keloid scarring, eczema, facial psoriasis, keratosis, or moles in the procedure area.

• You do not have diabetes, a history of hemophilia/abnormal bleeding, hair loss or any medical condition.

• You do not have any type of rash or infection anywhere on your body.

• You do not have freckles, moles or sunburn in the procedure area.

• You do not have any sensitivities to dyes or local anesthetics.

• You have/will received aftercare instructions and agree to follow them. You also agree that if you do not follow the instructions that any touch-up will be at your own expense.

• You acknowledge that you may have an allergic reaction to the pigments or anesthetic cream used during the procedure and accept the risk that such reaction is possible. Some medications and medical conditions MAY interact with the pigments or anesthetic cream (lidocaine).

• Infection is always possible as a result of procedure, particularly in the event that you do not follow the proper care following the procedure.

• You realize that variations in colour may exist between the colour selected and how it will ultimately look. This is especially true for tattoo cover-ups.

• You realize that tattoo cover ups will need more than just one touch up and that variations in colour will exist.

• After your procedure, you realize that the procedure are will be dark for approximately 6 day and will lighten after. Swelling and/or redness may occur.

• You are aware that the eyebrows naturally exfoliate in the first month and colour will fade significantly, as the skin heals and that this is completely normal.

• The final result will often not be obtained without returning for a touch up visit to reshape or augment areas within the eyebrow. This is usually done within 4-8 weeks after the initial appointment.

• Microblading will result in a semi-permanent change to your appearance and no representation has been made to your ability to later change or remove the result.

• Skin treatments such as laser hair removal, plastic surgery or other skin altering procedure may result in adverse changes to the procedure area.

• You acknowledge that if you any medical condition(s) you will need a medical note from your doctor.

• You acknowledge that all microblading needles are new, packaged, and only opened in front of you during your appointment.

• You acknowledge that it is not recommended to have someone in the room with you during your appointment. You and your guest may choose to accept the risk of blood borne pathogens but you will advise same prior to the appointment. Please note that due the risk of blood borne pathogens, eating, drinking, applying cosmetics or lip balms, and handling contact lenses are strictly prohibited in the procedure area.