How old are you?*
First & Last name
Date of Birth?
Address?
Phone Number
Please attach a photo of your ID* ❌ ❌
❌
Email
Gender MaleFemale
Are you pregnant?
Artist*
Procedure:*
Date of Procedure:*
Emergency Contact Name & Phone Number
Are you breastfeeding?
In order to perform the microblading treatment in a safe matter , we kindly ask you to give sincere answers to the following questions regarding your medical health.
Do you suffer from any of the following diseases , take any of the following medications , or have any of the listed conditions ? PregnancyHemophiliaNoneHepatitis A,B,C,D,E,FHerpesDiabetes MellitusEpilepsyHIV +Cardiovascular ProblemsEczemaSkin DiseasesAllergiesAutoimmune DiseasesInfectious DiseaseHigh TemperatureBlood Thinners ( Anticoagulants)Other
Please list and explain any other conditions you may have or medications you may take.
Do you take any medications on a daily basis?
Do you currently use retinol in your skin care routine? NoYes
Did you get Botox less than 10 days ago? YesNo
Have you had lip fillers in the last 10 days? YesNo
Have you ever gotten Microblading or any kind of permanent or semipermanent makeup? YesNo
Do you have a pacemaker fitted? YesNo
Do you have a problem with wound healing? YesNo
Have you consumed narcotics or alcohol in the past 24 hours? YesNo
Have you had surgery , laser therapy or any other medical intervention in the past 14 days? YesNo
Contractual Obligations
I consent to photography , filming , recording and/or digital imaging of the treatment to be performed and usage of the photos for advertising purposes. Yes
Upload a photo of your brows clean & with no makeup ❌ ❌
With this agreement, the Artist shall be exempt from all subsequent claims, demands, compensation of damages, actions and causes of action arising from the provided service.
The client is informed in detail by the Artist on the specific risks which may arise from the microblading treatment.
The following risks are particularly explained to me as a client:
Regardless of the staff's expertise and all safety precautions, an injury may occur during the treatment. Despite using the latest and best pigments, an allergic reaction is possible, but rare. The client is aware of that and bears responsibility.
During and after the treatment, a temporary swelling, redness and/or itching may appear. Our experience tells us these symptoms are transient in character. Depending on the skin structure, after the first procedure small scabs can occur followed by loss of drawn strokes and change in color intensity.
Quality of the skin is different in clients, the skin differently reacts to pigment insertion, hence there is no guarantee for treatment success.
Depending on the skin structure, it should be known that change in color intensity is possible and that one or more re-touch appointments will be required.
How long the microbladed eyebrows will last, minimum or maximum duration, cannot be precisely determined, nor can a guarantee on the performed treatment be made.
First refreshment is done four weeks after the procedure. The oily skin requires more refreshments.
Permanent make-up always leads to the skin injury. It is thus important to carefullyand gently nourish the skin after the treatment to ensure healing without complications.
Inadequate after care during the healing period may lead to poor results and the Artist does not bear responsibility for that.
The client is obligated to take notice of the following in the next 15 days:
Half an hour after the treatment, the eyebrows should be rinsed well with lukewarm wter and then a thin layer of vaseline should be applied. Repeat this procedure every hour at least 5 times daily in order to prevent formation of scabs. For after-care, use exclusively the given cream or the pure vaseline. Please do not use creams other than the given ones in order to prevent possible infections or allergic reactions. During the first two weeks after the procedure, avoid public baths, sun tanning, tanning beds, saunas, cosmetic treatments, and intense workouts accompanied by sweating (sport activities), contact with dust (chores, etc). The Artist does not bear responsibility in case of improper post-treatment care.
I agree
Clients Signature ❌ ❌
I certify that I am over the age of 18, I am not under the influence of drugs or alcohol, I am not pregnant or nursing, and I consent to receiving the microblading procedure. The general nature of microblading treatment to be performed has been explained to me. I understand that a certain amount of discomfort is associated with this procedure and that swollen, redness, and bruising may occur. I understand that Retin A, Renova, Alpha Hydroxy, and Glycolic Acids must not be used on the treated areas. They will alter the color. I understand that sun, tanning beds, pools, some skin care products, and medications can affect my final microblading result. I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I'm scheduled for an MRI (Magnetic Resonance Imaging). Understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, I will need to maintain the color with future applications and a touch up session within 6-8 weeks of initial procedure. Aftercare instructions have been explained to me which I will follow to the best of my ability. I confirm that I have read and understand the aforementioned information. I got a clear and comprehensible answer to all the questions I asked. The treatment procedure and the post-treatment care have been explained to me in detail and I agree to that. I did not get unrealistic guarantees regarding the expected results or the consequences of the said treatment. By signing the Consent, I certify that I had a chance to ask about everything related to the implementation of treatment and that the Artist provided me with clear and comprehensible answers to all my questions. I have no other questions or objections. I agree there will be no refunds for this elective procedure(s). I certify that I have read and fully understand the contents of this microblading consent form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I authorize the Artist entered above as my Eyebrow Microblading Artist to perform on my body the Eyebrow Microblading Procedure desired today.I hereby release and discharge Miami Brow Bar and its employees from any type of negligence, liability, claim, action, demand, and compensation in law and in equity, which I have or might have, now and hereafter; by reason of my request to be micro bladed. I also specifically release and forever discharge Miami Brow Bar and its employees and its agents, for any and all loss or damage on account of injury to my person or property caused by Miami Brow Bar, otherwise; by reason of my request to be micro bladed. I give permission to copyright and/or publish photographs of myself with or without my name in any such manner as deemed proper to their use. I realize that misrepresentation or falsification of information provided by me is a crime and is subject by prosecution. I further certify that I am over the age of eighteen and am not intoxicated or under the influence of any narcotic substance and made this statement entirely of free will and sound mind. I acknowledge that microblading is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my microblading. I acknowledge it is not reasonably possible for the representatives and employees of The Miami Brow Bar to determine whether I might have an allergic reaction to the pigments or processes used in my procedure, and I agree to accept the risk that such a reaction is possible. I acknowledge that infection is always possible as a result of the having this procedure, particularly in the even that I do not take proper care of my micro bladed eyebrows. This is a legal binding contract. I confirm that I have read and understand this Consent Form and I agree to be bound by it. I agree that all of the above information is true and accurate to the best of my knowledge.
Artist Signature ❌ ❌
