Microblading Consent Form - Vanity Brow & Beauty Room

Name *

First

Middle

Last

Email *

Phone *

Birthday *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you suffer from the following diseases or are you taking any of these medications?

In order to preform the eyebrow tattoo procedure in a safe manner, please answer the following questions truthfully

HEMOPHILIA *

No
Yes

DIABETES MELLITUS *

No
Yes

HEPATITIS A,B,C,D,E *

No
Yes

HIV+ *

No
Yes

SKIN DISEASES *

No
Yes

ECZEMA *

No
Yes

ALLERGIES (IF YES, PLEASE EXPLAIN) *

No
Yes

Allergy List

AUTO IMMUNE DISEASE *

No
Yes

DO YOU HAVE PROBLEMS HEALING OF WOUNDS *

No
Yes

ARE YOU PRONE TO HERPES *

No
Yes

INFECTIOUS DISEASE/HIGH FEVER *

No
Yes

EPILEPSY *

No
Yes

CARDIOVASCULAR PROBLEMS *

No
Yes

ARE YOU TAKING ANY MEDICATION FOR BLOOD THINNING *

No
Yes

ARE YOU PREGNANT OR NURSING *

No
Yes

ARE YOU TAKING MEDICATION ON A REGULAR BASIS *

No
Yes

DO YOU HAVE A PACEMAKER *

No
Yes

HAVE YOU CONSUMED ANY DRUGS IN THE LAST 24HRS *

No
Yes

Please read and INITIAL that you have read and understand the following:

IN THE FIRST 7 DAYS EYEBROWS ARE UP TO 40% DARKER AND 10% TO 15% THICKER. FOR EXAMPLE COLOR REFLECTION DEPENDS ON THE NATURAL SKIN PIGMENT *

THE SHAPE IS DETERMINED ACCORDING TO THE FACE PROPORTIONS *

DEPENDING ON THE SKIN STRUCTURE IT SHOULD BE NOTED THAT CHANGES IN THE COLOR INTENSITY IS POSSIBLE AND THAT ONE OR MORE ADDITIONAL TREATMENTS Will BE REQUIRED *

TOUCH UP FEES MAY APPLY FOR FUTURE APPOINTMENTS. IF MOST OF THE COLOR HAS FADED THEN THIS WILL NOT BE CONSIDERED A TOUCH UP AND ALL FEES FOR A NEW SERVICE MAY APPLY. TOUCH UPS ARE USUALLY PERFORMED AFTER 6 TO 8 WEEKS FOR OILY SKIN. IT MAY BE NECESSARY TO PERFORM MORE CORRECTIONS *

PERMANENT MAKE UP ALWAYS LEADS TO SKIN INFLAMMATION, THEREFORE IT IS IMPORTANT TO CAREFULLY AND GENTLY NURTURE YOUR SKIN AFTER THE TREATMENT TO ALLOW HEALING WITHOUT COMPLICATIONS. INADEQUATE CARE. IMPROPER CARE, OF FACE AND SKIN CAN LEAD TO POOR RESULTS AND YOUR TECHNICIAN CANNOT BE HELD LIABLE *

IN THE NEXT 10 DAYS THE CLIENT IS REQUIRED TO PAY ATTENTION TO THE FOLLOWING

KEEP YOUR EYEBROWS DRY AND CLEAN FOR THE NEXT 10 - 14 DAYS *

DO NOT TOUCH THE SCAB IN ANY CASE EXCEPT WHILE CLEANING *

PLEASE DO NOT USE ANY OTHER CREAMS EXCEPT THE ONES PROVIDED OR RECOMMENDED TO YOU IN ORDER TO PREVENT A POSSIBLE INFECTION OR ALLERGIC REACTION *

IN THE FIRST 2 WEEKS AFTER THE TREATMENT AVOID SWIMMING POOL, SUNBATHING, TANNING BEDS (FOR 30 DAYS), OR SAUNA. AVOID PROLONGED TIME OF STEAM EVEN FROM THE SHOWER. NO HARSH FACIAL TREATMENTS OR PRODUCTS, EXAMPLES: RETINOIDS, GLYCOLIC ACIDS, SALICYLIC ACIDS. *

YOUR TECHNICIAN IS NOT LIABLE IN CASE OF AN IMPROPER POST-TREATMENT CARE *

I UNDERSTAND THE SERVICE REFUND POLICY THAT STATES THERE IS NO REFUNDS GIVEN FOR ANY SERVICE *

I ACKNOWLEDGE THAT NO GUARANTEES WERE MADE TO ME CONCERNING THE RESULTS OF THIS PROCEDURE *

I RECEIVED A CLEAR AND UNDERSTANDABLE RESPONSE TO All MY QUESTIONS *

I CONFIRM THAT I HAVE READ AND UNDERSTOOD THE ABOVE MENTIONED INFORMATION *

THE TREATMENT PROCEDURE AND POST-TREATMENT CARE WAS EXPLAINED TO ME IN DETAIL *

Date *

Your Signature *

Date / Time

Date

Time