consultation form

Microblading Treatment Consent Form

Consultation
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?

Do you suffer from any of the following?

Do you have any previous permanent make up?

Are you over the age of 18?

Have you had Botox or Injectables?


Do you currently or have you ever had Cancer?

Are you taking antibiotics for dental or invasive medical procedures?

Are you taking Vitamins A, E or Fish Oil?

Do you have problems with healing?

Do you take Antidepressant medication?

Are you currently under going chemotherapy or radiation?

Have you had caffeine or alcohol in the last 24 hours?

Are you currently using Retin-A or Alpha Hydroxyl skin care products?

Are you taking any anti-inflammatory or steroids?

Are you allergic to tropical antibiotics, Polysporin, Bacitracin, Neosporin or Petroleum based products?

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

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

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

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

After care Instructions
I confirm that Aftercare procedures have been explained to me in detail along with an after care sheet with instructions to take home.

Upload your pictures
Please upload your pictures (Before/After)




Client Treatment Procedure Report

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Draw inside the box below

Mailing List

Before & After

Semi Permanent Make Up is also known as Micropigmentation which is a delicate controlled method of applying subtle micro insertions of pigments to the skin.

 

The technique is similar to a standard tattoo however pigments are used instead of ink and a Microblading tool is used instead of a digital machine.

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