Microblading Treatment Consent Form
Your Full Name
D.O.B
Your Email
Telephone
Address
Postcode
Consultation
Do you have any persistent medical conditions such as allergies?
Yes No
Are you pregnant or breast feeding?
Yes No
Specify any past or impending medical operations?
Do you have any of the following?
Pacemaker Heart Disease Diabetes High Blood Pressure Epilepsy Seizure of any kind) Autoimmune Disorders HIV Alopecia Keloid scar Hypertrophy Scar
Do you have any skin problems?
Eczema? Dermatitis? Acne? Vitiligo? Skin Cancer? Skin Diseases Skin Sensitivities
Do you suffer from any of the following?
Haemophilia? Cold Sores?
Do you have any previous permanent make up?
Yes No
If yes when?
Are you over the age of 18?
Yes No
Have you had Botox or Injectables?
Yes No If yes when?
Do you currently or have you ever had Cancer?
Yes No
If yes, please explain?
Are you taking antibiotics for dental or invasive medical procedures?
Yes No
Are you taking Vitamins A, E or Fish Oil?
Yes No
Do you have problems with healing?
Yes No
Do you take Antidepressant medication?
Yes No
Are you currently under going chemotherapy or radiation?
Yes No
Have you had caffeine or alcohol in the last 24 hours?
Yes No
Are you currently using Retin-A or Alpha Hydroxyl skin care products?
Yes No
Are you taking any anti-inflammatory or steroids?
Yes No
Are you allergic to tropical antibiotics, Polysporin, Bacitracin, Neosporin or Petroleum based products?
Yes No
Have you ever had Hepatitis?
Yes No
Do you bruise easily?
Yes No
Do you wear glasses?
Yes No
Have you ever or are you contemplating facial surgery?
Yes No
If yes, please specify
Do you have any other medical issues not including in the above?
Yes No
If yes, please specify
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?
Yes No
Practitioner notes:
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:-
Yes No
Treatment
Expected no. of visits
(The fee will remain the same if additional visits are required)
Total Fee
(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.
Yes No
