Personal Information Name & Surname Date Address Email Phone Date of Birth Who Referred you? General Have you had any previous microblading/shading or permanent make? Yes No Please list any prescription medication you are currently taking: Confidential Medical Profile Please tick where appropriate Heart Condition Diabetes requiring insulin Hemophilia Keloid Scarring Seizures or Epilepsy Skin Allergies Trichotillomania Alopecia Fainting Spells Hepatitis HIV Radiation/Chemotherapy Low Blood Pressure Excessive Bleeding Problems with healing Please tick where appropriate Retin-A Tanning Beds Botox / Fillers Chemical Peels / Facials Laser Treatments Blood Thinning Medication Caffeine Products (last 24 hours) Vitamins A, E or Fish Oil (last 7 days) Accutane Treatment Brow Tinting Steroids / Cortisone Cream Female Clients only Are you, or is it possible you may be pregnant? Yes No Initial Procedure Details Are you currently breast feeding? Yes No For Office Use Only Date Therapist: Price Quoted: Pigment Used: Needle Used: Comments: Touch Up Procedure Details Date Therapist: Price Quoted: Needle Used: Comments: Pigment Used: Digital Consent Form Consent Form consent to the below: am over the age of 18 and • The general nature of the microblading/shading procedure has been explained to me and I understand the possible consequences. • I understand microblading/shading is semi-permanent and more than one procedure is required to achieve the desired results. • I am aware that the pigment will fade and the full colour retention will vary based on my aftercare and my skin's ability to retain pigment. • I accept responsibility for approving the final shape and position of my eyebrows. • • I fully understand that microblading/shading is an art and not a science, and I should not receive the treatment if I have unrealistic expectations. I realize that this is an elective cosmetic procedure and is not medically necessary. The aftercare instructions have been explained to me and I am aware that failure to follow these guidelines will compromise the standard of the final result. I have been given the opportunity to ask any questions about the procedure and the risks involved. • I have disclosed all relevant medical conditions to my technician. It has been explained to me that the following may occur: minor bleeding. bruising, redness, swelling and fading or loss of pigment. • I am aware that if I receive botox or cosmetic surgery after my microblading/shading procedure, it can affect the position of my brows. • I am aware that if I receive an MRI after the procedure, I must inform the radiologist that I have iron oxide cosmetics. • I understand that laser and IPL treatments can affect the colour of my pigment and I must therefore inform my technician that I have iron oxide cosmetics before receiving any laser treatments. • If an infection occurs after my microblading/shading procedure I must seek medical advice immediately. If I have had permanent cosmetic procedures performed previously on my brow area, I cannot hold my current technician responsible for the final colour result. Send