Name:

DOB:

Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Age ____________ Have you received chemotherapy or radiation in the past year? Have you ever had an allergic reaction to any of the following (please circle): Latex Lanolin Vaseline Medication Metals Hair Dyes Foods Lidocaine Paints Crayons Glycerin Have you ever had a cold sore? Yes No If yes, contact your physician for a preventative prescription capsule to prevent a cold sore. Are you currently taking medication that thins the blood? Yes No Are you currently under the care of a physician? If yes, please explain: Physician’s Name Do you take antibiotics when going to the dentist? If yes, why? Have you ever had one of the following (please circle): Hair Loss Anemia Sensitivity to cosmetics Prolonged bleeding Diabetes Trichotillomania Epilepsy Artificial Heart Valve Low Blood pressure High Blood Pressure Hemophilia HIV Fainting spells or dizziness Circulatory Problems Hypertrophic or keloid scars Liver Disease Alopecia Tumors, growths, cysts Botox/filler injections Hepatitis Thyroid disturbances Cancer Healing problems Do you scar easily? Do you bruise/bleed easily? What would you like to improve about your eyebrows? Consider shape, color, density, thickness… Please read the following statements carefully. Microblading is a way of cosmetic tattooing, intended to be semipermanent 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 after care information and I’m fully aware of the after care procedures. I fully understand the information provided above & confirm that all information provided by me is correct and truthful. Client’s Name Client’s signature Date Technician’s Name Technician’s signature Date For therapist use - Note pigments/blades used for this client