What are the main concerns relating to your eyebrows?
Microblading is a way of cosmetic tattooing, intended to be semi- permanent lasting average 12-18 months. On a rare occasion, the pigment may migrate
under the skin. Procedure of microblading may be uncomfortable. 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 full procedure. Allergic reactions to anesthetic can occur.
Permanent cosmetics cannot be performed if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not
followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months
after microblading procedure, you should notify/discuss with your doctor. Possible scarring may occur.
I have received an aftercare leaflet and I’m fully aware of the aftercare procedures.
I have fully understood the information provided above.
I can confirm that all the information provided by me, is correct and truthful.
Microblading procedure normally requires multiple treatment sessions. For best results, clients will be required to return for
at least one re-touch appointment. This will take place 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 numbing cream is used during the procedure, sensitivity or discomfort may still be felt. Skin may be red and/or swollen
after the procedure.
• Please do not drink alcohol 24 hours prior to the treatment.
• Where possible, try to avoid the following herbs and spices prior to your appointment: Black pepper, Cardamom, any member of
the Zingiberaceae (Ginger) family, Cayenne, Cinnamon, Garlic, Horseradish, Mustard.
• A patch test will be performed, unless waived by client.
• Please do not shape or wax your brows before the procedure. Your technician will shape brows during the procedure.
• No electrolysis for at least 5 days before the procedure.
• Botox, AHA products and retinoids should be avoided for 2 weeks prior to the procedure.
• Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure.
• Chemical and laser peels should be avoided no less than 6 weeks prior to procedure.
• Patients prone to cold sores/fever blisters should take an anti-viral prior to treatment.
• Hormone therapies can affect pigmentation and/or cause sensitivity.
Topical Anesthetic Advice
• Allergic reaction can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you
should contact your doctor immediately. Allergic reaction response 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 cream. Each individual is
different according to skin type. Some clients report the area to be completely numb, while others may experience some discomfort.
• Procedure: For microblading procedure, a numbing cream/gel is used. The products are formulated to be perfectly safe and can be
purchased over the counter from any pharmacy/chemist. The anesthetic is placed over the treatment area for 20-30 minutes then
carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to
experience some redness/swelling that can last 1-4 days. You should always follow your post procedure advice and after care for the
Contraindications for Microblading
• Liver disease – high risk of infection • Pregnancy/Nursing • Compromised skin near brow area • Chemotherapy/Radiation
The following medical conditions require a note from your doctor giving consent
Diabetes Type 1 and 2, high blood pressure, auto-immune disease, thyroid / Graves’ disease.
Any other medical condition that causes slow healing or a high risk of infection.
I___________________________________ 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 semi-permanent pigmentation procedure. The general nature of cosmetic micropigmentation, as well as the specific procedure to be performed, has been explained to me.
• If an unforeseen condition arises in the course of the procedure, I authorize my therapist to use his/her professional judgment to
decide what he/she feels is necessary under the given circumstances. I accept the responsibility for determining the color, shape and
position of the microblading procedure as agreed during consultation. I fully understand and accept that non-toxic pigments are used
during the procedure and that the result achieved may fade over a period of 1-3 years. Even once the color fades, pigment itself may
stay in the skin indefinitely.
• 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.
• I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and
that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeated procedure.
• The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin
skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care.
• Upon completion of the procedure there might be swelling and redness of the skin, which will 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 after care instructions for more
details. The procedure results will look acceptable for you to appear in public without additional make-up on the brows.
• I have been advised that the true 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.
• To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct
or indirect result of my decision to have the procedure done at this time.
• I agree to follow all pre-procedure and post-procedure instructions as provided and 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 after care details.
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 procedure, including but not limited to: infection, scarring, inconsistent color, and 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 procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences of
the said procedure ________ (initial)
C O N S E N T F O R M
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There is a possibility of an allergic reaction to numbing agent and/or pigments. 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 the pigment.
Initial one or the other, not both:
I consent ________ (initial) to the patch test OR I waive ________ (initial) the 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 procedure. I acknowledge some of these potential adverse changes may not be
correctable. ________ (initial)
I certify that I have read and initialed the above paragraphs and have had explained to my understanding the consent and procedure permit.
I accept full responsibility for the decision to have this cosmetic semipermanent pigmentation work done.
Please read and initial all lines:
I would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is
necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.
We also like to tag our clients in photos used on our Instagram profile! Please indicate if you’d like to allow this or not below
Possible Risk, Hazards or complications
Excessive Swelling or Bruising:
Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-5 days.
Some people don’t bruise or swell at all.
There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.
This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven
Every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up
session to correct any unevenness.
There is a small risk of eye injury when an eyeliner procedure is performed. To avoid corneal abrasion, Celluvisc, a thick eye drop is
used to protect the eye prior to the procedure. Eye drops are used to cleanse and flush the eye after the procedure is complete.
Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream
or gel form are typically used. If you are allergic to any of these please inform me now.
Because pigments used in permanent cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be
scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.
Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care”
sheet for instructions on care.
There is a small possibility of an allergic reaction. You may take a 5-7 day patch test to determine this.
Please initial to: Waive___________ or Take___________ .