Artist Name: ______Date: ______
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING
Name:______
Are you over the age of 18? Date of Birth: Yes or No ______
Phone Number: ______
Address: ______
Email:______======What are the main concerns relating to your eyebrows?
What would you like to improve about your eyebrow?
What is your desired shape, color, density, and thickness?
Do you take antibiotics when going to the dentist? If yes, why?
Are you currently taking medication that thins the blood? Yes No
List any medications you have been taking in the past 6 months:
Are you currently under the care of a physician? Yes No
If yes, please explain: ______Physician’s Name: ______
Physician’s Telephone: ______
Have you received chemotherapy or radiation in the past year? Yes No Do you experience excessive sweating? Yes No
Have you ever had an allergic reaction to any of the following? (Please circle) Latex Lanolin Vaseline Medication Metals Disinfectants Soaps Lidocaine Paint Crayons Hair dyes Glycerin Pigments/Dyes
Have you had a cold sore within the past 6 months? If so please provide date: ______If yes, you must contact your physician for a preventative prescription capsule to prevent a cold sore.
Circle what applies:
Retin- A in past 2 weeks Hypertrophic scars Anemia Liver disease Sensitivity to cosmetics Jaundice Prolonged bleeding Alopecia Diabetes Tumors, growths, or cysts Trichotillomania Cancer/ Skin Cancer Epilepsy Keloid scars Artificial Heart Valve AHA’s in the past 2 weeks Low blood pressure Hair loss High Blood Pressure Hepatitis Hemophilia Scar easily HIV/AIDS Pregnant or Lactating Fainting spells or dizziness Menopause Circulatory problems Chemical peel Thyroid disturbances Laser Peel Skin Disease Skin Lesions Seizures Narcolepsy Eye Disease
Anaphylactic reaction to pigment, dyes, or other sensitivities. If yes, please circle & provide date______
Botox/Filler injections. If yes, please state the last treatment date:______
Any other information that would aid the body art technician in determining the client’s suitability for receiving a body art procedure and the client’s body healing process______
Any client reporting one or more of the above conditions shall advise clients to consult his/her physician before undergoing a body art procedure.
For practitioners use ONLY Note: Pigments, blades, techniques used for this client ______
Please read the following statements carefully and thoroughly.
I understand that Microblading is a semi-permanent (permanent) two-step cosmetic procedure.
I am fully aware that a touch up procedure is required 4-6 weeks later in order to achieve my desired look.
I am fully aware that a healing period of 4-6 weeks is required before a touch up procedure can be performed.
I am fully aware that under unique circumstances I may need an additional touch up depending on my skin type, DNA, and how well I retain color.
I understand that permanent cosmetics cannot be applied if I am currently pregnant or lactating.
I am aware that anyone under the age of 18 is not allowed to have this procedure done, unless accompanied by a parent or guardian.
Photo ID must be presented for both the initial appointment and touch up appointment before the procedure.
I understand that microblading may be slightly uncomfortable and I may experience minor bleeding.
I understand that I may experience some swelling, redness, and tenderness after my procedure.
I am aware that possible scarring may occur but is extremely rare.
Although extremely rare, there might be an immediate or delayed allergic reaction to pigment.
A negative patch test result does not guarantee that you will not develop an allergic reaction after the procedure.
Allergic reactions to anesthetic can occur. Risks, Effects, and Permanence: A tattoo is a permanent mark or design made on skin with pigments that are inserted by needles piercing the top layer of the skin repeatedly. Body art procedures may cause slight bleeding and pain. Because body art procedures breach the skin, infections and other complications are possible. In some people, tattoo pigments can cause allergic skin reactions. Infections can occur from use of unsterile equipment or not following proper aftercare. A procedure done with contaminated equipment may cause the contraction of various blood borne diseases such as hepatitis B, and HIV. Other skin problems such as granulomas (nodules that may form around material the body perceives to be foreign) or keloids (raised areas caused by an overgrowth of scar tissue) can occur for certain people. Tattoos can cause complications with MRI (magnetic resonance imaging) procedures such as an interference with the image and swelling or burning after the MRI. Tattoos may be able to be removed with laser technology, but removing a tattoo usually involves several painful and expensive treatments and complete removal without scarring may not be possible.
By signing this consent form: • I confirm the information provided by me is truthful and accurate to the best of my knowledge. • I have read and understand the written information regarding the risks, effects and permanence of body art procedures. • I have been provided with verbal and written aftercare information. • I am not under the influence drugs or alcohol. • I have been provided with a copy of this record.
Client’s Name (Print): ______
Client’s Signature: ______
Date: ______
Practitioner’s Name: ______
Practitioner’s Signature: ______
Date: ______MICROBLADING AFTER CARE FORM
Day/Night One • Blot every 2 hours with a clean tissue to pick up any serous fluid. • Using your fingertips, wash gently with facial cleanser at night. Make sure your hands are washed and sanitized before doing so. • Blot completely dry with a tissue after washing brows because moisture can be a cause for scabbing. You want to scab as little as possible. • Apply small amount of post treatment recovery balm (A&D Ointment) to your brows with a q-tip at night to add some moisture. Do not over saturate your brows.
Day/Night Two • Using your fingertips, wash gently with a fragrance & dye free soap in the morning. Make sure your hands are washed and sanitized before doing so. • Blot completely dry with a tissue after washing brows because moisture can be a cause for scabbing. You want to scab as little as possible. • Using your fingertips, wash gently with facial cleanser at night. Make sure your hands are washed and sanitized before doing so. • Apply small amount of post treatment recovery balm (A&D Ointment) to your brows with a q-tip at night to add some moisture. Do not over saturate your brows.
Be sure to follow Day/Night 2 throughout the rest of your healing process.
TIPS • Because your brows are an open wound, avoid touching your brows as much as possible so you can avoid infections. • No makeup for at least 7 days until your eyebrows have completely scabbed over. You are only allowed to wear eyeliner and mascara. NO foundation, concealer, eyeshadow, or brow pencil at all because makeup travels and carries bacteria along the way. • Be mindful to sleep on your back the first 3 nights to avoid irritation to your brows. Also, a clean pillowcase is highly recommended to steer clear of infections. • DO NOT TOUCH THE BROWS WITH UNSANITARY HANDS. • Keep your hair out of your face as much as possible. • Avoid sun tanning, spray tanning, hot yoga, and saunas for 30 days. • No excessive exercising that will cause you to sweat because moisture can be a cause for scabbing. If need be, we advise you to wear a sweatband. • Avoid direct sun exposure for 30 days as the UV- rays might alternate your pigment color. • Avoid sunburn, salt, chlorine water, and hot tubs until your eyebrows have completely healed • BE MINDFUL TO SHOWER NECK DOWN & AVOID HOT STEAMY SHOWERS • To wash your hair, have your back turned towards the shower head to avoid water on your brows. • You may be allowed to donate blood within the standard deferral period if you present a copy of your client record provided by the body art facility to the blood donor facility. • At the first sign of infection please contact your physician immediately. Signs of infection may include pain, redness, swelling, rash, or discharge at the sight of tattoo, or fever.
***Microblading is at minimum a two-step procedure. You must return for your touch up in order to complete the procedure. NOT TO WORRY... • Brows will appear extremely dark the 2nd & 3rd day as the pigment is oxidizing with the blood. • Your brows will start to flake and scab as you begin the healing process, be mindful NOT to pick at them. Just let the scabs and flakes fall off naturally. • When itchiness occurs the best way to handle is by simply patting your brows, do not scratch under any circumstances. • Depending on how fast your body is able to heal between day 8-14 your brows may seem as if they have completely disappeared, but this is normal as the brows are just underneath the skin, just as any tattoo or scab. You will return for your touch so we can exfoliate and reinforce and strokes that may have gotten lost during the healing process. • We ask that all of our clients trust the process! ***Please note that this is a general conclusion on your healing process because everybody's body, DNA, and skin all vary. Disclosure Statement /Notice for Filing Complaints
Public Act 375, which was enacted in December of 2010, indicates that individuals shall not tattoo, brand, or perform body piercing on another individual unless the tattooing, branding, or body piercing occurs at a body art facility licensed by the Michigan Department of Health and Human Services. Body art facilities are required to be in compliance with the “Requirements for Body Art Facilities,” which provide guidelines for safe and sanitary body art administration. As with any invasive procedure, body art may involve possible health risks. These risks may include, but are not limited to: transmissions of bloodborne diseases such as HIV and viral hepatitis, skin disorders, skin infections, and allergic reactions. In addition, persons with certain conditions including, but not limited to, diabetes, hemophilia or epilepsy, are at a higher risk for complications and should consult a physician before undergoing a body art procedure. If you wish to file a complaint against a body art facility related to compliance with PA 375 or have concerns about potential health risks, please visit www.michigan.gov/bodyart. Or, to make a complaint, contact the Oakland County Health Division at 248.424.7190 or 248.858.1312.
______Signature of Artist Date
______Signature of Client Date Microblading Client or Model Photo Release Agreement
Client/Model Name:______
I hereby consent and authorize the use of my image and/or videos for personal records purposes, as well as advertisement purposes. I am aware that before, during, and after photos and/or videos will be taken throughout the procedure.
I understand that my identity will be protected and neither my full face or full name will be released to the public unless I have signed off permission.
The microblading practitioner has explained that all the photos and/or videos will be clinically appropriate and tastefully presented.
I have agreed that any photos and/or videos that has been taken by the Microblading Practitioner may be used by the artist or company owner for website, social media accounts i.e Facebook, Instagram, Twitter, and Snapchat for promotional purposes.
I understand that my photos and/or videos may be used in office demonstration and promotional purposes.
I understand that I am not entitled to compensation for these photos being used.
I have entered into this release freely and voluntarily and agree to be bound thereby.
Client/ Model Signature:______Date:______Practitioners/Witness Signature:______Date:______