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This form is used to instruct patients the pre- and post-guideline instructions for a microblading procedure. Please read over the guidelines fully before signing. A copy of this form will be emailed to you to reference back to it at any time.

Microblading Pre-Procedure Guidelines

Please review the following guidelines very carefully and initial that you have read and understood.

  • A microblading procedure usually requires multiple treatment sessions. For best results, clients will be required to return for at least one touch up appointment. This will take place 4-6 weeks after the initial procedure. Those with oily skin may require an additional touch up. Please be aware that color intensity will be significantly darker and sharper immediately and a few days after the initial procedure, but the color will reduce by 30-50%.
  • Although a topical numbing cream is applied during the procedure, sensitivity or discomfort may be felt. Skin may be red and/or swollen after the procedure.
  • Please avoid coffee on the day of your procedure.
  • Please do not drink alcohol at least 24 hours prior to the procedure.
  • Where possible, avoid the following herbs and spices prior to your appointment: black pepper, cardamom, any member of the zingiberaceae (ginger) family, cayenne, cinnamon, garlic, horseradish and mustard.
  • Do not shape or wax your eyebrows before the procedure. Your technician will shape brows during procedure.
  • No electrolysis at least 5 days before the procedure.
  • No botox, AHA products, retinoids, exfoliating or resurfacing treatments (like microdermabrasion) for at least 2 weeks prior to procedures.
  • No chemical peel or laser treatments at least 6 weeks prior to procedure.
  • Patients prone to cold sores and fever blisters may request an anti-viral prior to procedure.
  • Please note that hormone therapies can affect pigmentation and/or cause sensitivity.

I understand that these guidelines are set forth for my comfort and safety for a microblading treatment. If I do not follow these instructions prior to my appointment, I understand that I may need to reschedule.

 

Topical Anesthetic Advice

  • Procedure For microblading procedures, a numbing agent is used. The products are formulated to be safe and are prescribed for topical numbing for cosmetic procedures. The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to procedure. As a result of the treatment, combined with use of the anesthetic, you can expect to experience some redness or swelling that can last 1-4 days. You should always follow your post-procedure and aftercare guidelines for best results.
     
  • Allergic Reaction may occur from any anesthetics used during the procedure. Pure Cosmetics will provide the patient with application of a 20% benzocaine, 6% lidocaine and 4% tetracaine numbing agent. If you know that you are allergic to any of these ingredients, please notify your technician prior to procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction responses may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.
     
  • Numbness We cannot accept responsibility if the area to be treated does not respond to the numbing agent. Each individual is different. Some clients report the area to be completely numb, while others may experience some discomfort.

I understand that a topical numbing agent will be used by my technician for my comfort. I understand it is my responsibility to notify my technician if I have a known allergy and/or that I need to contact my doctor immediately if I present with any allergic reaction symptoms.

 

Contraindications for Microblading

  • Liver disease: high risk of infection
  • Pregnancy/Nursing
  • Chemotherapy/Radiation
  • Compromised skin near brow (rash, pimples, boils, infections, manifests of being reddened or inflamed)

I understand there are certain contraindications for microblading treatment. To the best of my knowledge, I have disclosed if I have any of the above contraindications and understand that it will deem me as a non-candidate for treatment.

 

Consent for Certain Medical Conditions

The following medical conditions require a note from your doctor giving consent:

  • Diabetes Type I and II
  • High Blood Pressure
  • Auto-Immune disease
  • Thyroid/Grave’s disease
  • Any medical condition that causes delayed healing responses
  • Any medical condition that carries a high risk of infection

I understand that certain medical conditions require a note from my doctor giving consent for the microblading procedure. I will provide this prior to my appointment.

I have read and fully understand the above information regarding pre-procedures protocol for microblading. I agree to follow pre-procedure guidelines closely and and understand the risks of using a topical anesthetic. I consent to the use of a topical anesthetic during the procedures.

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Informed Consent for Microblading
I, the patient, am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing, and desire to receive the indicated permanent pigmentation procedure. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed, has been explained to me. The microblading procedure requires 2 visits (in some cases, more may be required) and the cost is $595. Scheduled appointments for the touch up procedure require 48 hours notice for cancellation or rescheduling, and are included in the original price ONLY when performed within 8 weeks of the original procedure. Outside of 8 weeks, or if scheduled appointments are "no-showed", a fee will apply.*
No
Yes
If unforeseen circumstances arise in the course of the procedure, I authorize my technician to use his/her professional judgement to decide what he/she feels necessary under the given circumstances. I accept responsibility for determining shape, color, and position of the microblading procedure as agreed upon during consultation. I fully understand and accept that non-toxic pigments are used during the procedure and that the achieved result may fade over a period of 1-3 years. Even once the color fades, pigment itself may stay in the skin indefintely.*
No
Yes
I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers are used for each individual client, procedure, and visit.*
No
Yes
The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged, thin/thickness), personal pH balance of skin, alcohol intake, tobacco use, and post-procedure aftercare.*
No
Yes
Upon completion of the procedure, there may be swelling and redness of the skin which should subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration, and exposure to the sun should be limited until the skin has fully healed. Please see post-procedure or aftercare instructions for more details. The procedure results will look acceptable for you to appear in public without additional makeup on the brows.*
No
Yes
I have been advised that true skin color will be seen 6 weeks after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.*
No
Yes
To my knowledge, I do not have any physical, mental or medical impairment or disability that may affect my well being as a direct or indirect result of my decision to have the procedure done at this time.*
No
Yes
I agree to follow all pre-procedure and post-procedure instructions as provided and have been explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure. I can confirm that I have received a copy of the after care details.*
No
Yes

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedures, including, but not limited to: infection, scarring, inconsistent color, spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the semi-permanent skin pigmentation procedures(s) and accept the permanence of this procedure, as well as the possible complications and consequences of said procedure by typing my full name in the text box. *
There is a possibility of allergic reaction to numbing agents, and/or the pigment. A patch test is offered, however it does not ensure a client will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to pigment.*
No, I waive the patch test.
I consent to a patch test.
I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery, or other skin altering procedures, it may result in adverse changes to my microblading procedures. I acknowledge some of these potential adverse changes may not be correctable.*
No
Yes
Signature

Please type your full name in the box above if you certify that you have read and initialed the pre-and post-procedure guidelines, and medical history. The above has been explained to my understand and consent for a microblading procedure to be completed. I accept full responsibility for the decision to have this cosmetic, semi-permanent pigmentation work completed. *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Health Information

List any medications have have taken in the past 6 months:
Have you received chemotherapy or radiation in the past year?*
No
Yes
Check any of the following that you have ever had an allergic reaction to:
Latex
Lanolin
Vaseline
Medications
Metals
Hair Dyes
Foods
Lidocaine/Numbing Agents
Paints
Crayons
Glycerin
Have you ever had a cold sore or fever blister?*
No
Yes
Are you currently on any medications that classify as a blood thinner?*
No
Yes
Are you currently under the care of a physician?*
No
Yes

If so, please explain:
Do you take antibiotics with routine dental visits?*
No
Yes
Please check any that you have ever been treated with/for, diagnosed or prescribed with:
Retin-A
Hair Loss
Trichotillomania Hemophilia
Liver Disease
Thyroid Disturbances
Anemia
Epilepsy
HIV
Cancer
Hepatitis
Sensitivity to Cosmetics
Artificial Heart Valve
Fainting spells or dizziness
Tumors, Growths or Cysts
Healing Problems
Prolonged Bleeding
Low Blood Pressure
Hypertropic Scarring or Keloid Formation
Circulatory Problems
Diabetes
High Blood Pressure
Easy Bruising

What would you like to improve about your eyebrows (ie shape, color, density, thickness) *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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