Consultation Form

Microblading Treatment Consent Form

Do you have any persistent medical conditions such as allergies?

Are you pregnant or breast feeding?

Do you have any of the following?

Do you have any skin problems?

Have you ever had Hepatitis?

Do you bruise easily?

Do you wear glasses?

Have you ever or are you contemplating facial surgery?

Do you have any other medical issues not including in the above?

I certify that the information given on this form is accurate and that I know of no reason why I should not proceed with the treatment?

I certify that I am over the age of eighteen years old and that I am not under the influence of either drugs or alcohol. I further certify that I have received a full consultation and that the procedure of microblading treatment has been explained to me fully and in detail and I wish to receive the treatment given below:-

(The fee will remain the same if additional visits are required)

(payable IN FULL at the first appointment)

I AGREE WITH THE SHAPE AND COLOUR THAT HAS BEEN CHOSEN

I also understand that microblading is a tattoo and carries with it possible consequences associated with the type of procedure, including but not limited to infection, scabbing, inconsistent colour and spreading or fading of the pigments. I also understand that the colour may, at first, appear too dark, but that up 50% of colour may be lost as scabbing clears; usually within seven days of the first treatment and that further treatment(s) may be needed to achieve the correct colour balance.

I have been given both pre and post operative instructions, to which I will strictly adhere. If I ever develop cold sores I will consult with and strictly follow my GP’s instructions.

I understand that my Practitioner is required to take photographs of the treatment areas before and after every microblading procedure and agree to this being carried out.

I have read the above paragraphs and have the full treatment procedure and consent requirements explained in detail to me and hereby give my consent to the the treatment(s) detailed above being performed.

Consent Agreement Form

Patch Test

(Please mark a tick in the boxes provided)

I confirm that I have taken a patch test 24hrs before receiving microblading treatment

YesNo

I have elected not to have a patch test before receiving microblading treatment

YesNo

EMLA Numbing Cream

I confirm that I have purchased my own EMLA numbing cream and I will be applying the numbing cream onto myself

YesNo

I have agreed to use EMLA numbing cream which has been provided by the Mircoblading
Technician but will be applying the numbing cream onto myself

YesNo