If you are unsure about a particular detail of the form, please speak to your artist. If unforeseen condition arises in the course of the microblading procedure, I authorize my artist to use their professional judgement to decide on what he/she feels necessary in the given circumstances.

Client Initials

I accept the responsibility for determining the color, shape, and position of the microblading procedure as agreed during consultation. I understand that an allergy test does not guarantee that I will not develop an allergic reaction to the pigment.

Client Initials

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 will fade, pigment itself may stay in the skin indefinitely. I have been informed that the highest standards of hygiene are met and sterile, disposable needles, and pigment containers are used for each individual client, procedure and visit.

Client Initials

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.

Client Initials

The result of the procedure is determined 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.

Client Initials

Upon completion of the procedure there might be swelling and redness of the skin, which will subside between 1-3 days. In some cases, bruising may occur. You may resume your normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure of the sun should be limited until the skin has fully healed. Please see after care card for more details. You can be assured that the procedure results will look acceptable for you to appear in public.

Client Initials

I have been advised that the true color will be seen 1 month 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.

Client Initials

To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my wellbeing 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 artist. I can confirm that I have received a copy of aftercare details.

Client Initials

Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequences that might stem from my decision to have any permanent cosmetics procedure performed by Carrie Bui.

Client Initials

Client Information

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Driver's License #

Today's Date

YYYY

Photography Release Consent

Client Consent

First Name

Last Name

For the purpose of documentation and record, “before” and “after” photographs and videos of your procedure will be taken.

We 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 select below and indicate if you consent to your photos being used in advertising.

Client Medical Health History

First Name

Last Name

List any medications you have been taking in the past 6 months:

Have you received chemotherapy or radiation in the past year?

If yes, a Dr's note is required for clearance to proceed.

Healing problems

Scar easily?

Bruise or bleed easily?

Currently pregnant or nursing?

None of the above

What are the main concerns relating to your eyebrows? What would you like to improve?

MICROBLADING PRE PROCEDURE ADVICE

Read the following advice carefully and sign at the end.

Microblading & shading 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 between 6-8 weeks after the initial procedure.

Client Initials

Please be prepared that color intensity will be significantly darker and sharper immediately after the procedure. Color intensity will reduce by 30%-50%. Although numbing cream is used during the procedure, slight sensitivity/ discomfort can be still felt by sensitive clients. Delicate or sensitive skin may be red and/ or swollen after the procedure.

Client Initials

Please wear your normal makeup to the salon on the day of your procedure and bring your makeup to touch up for pictures.

Client Initials

Please do not drink alcohol, coffee, or take fish oil the night before or the day of the treatment. Where possible, try to avoid the following herbs and spices running up to your appointment: Black pepper, Cardamom, (Ginger), Cayenne, Cinnamon, Garlic, Ginger, Horseradish, Mustard

Client Initials

Electrolysis treatment should be undergone no less than 5 days before the treatment. Brow waxing should be done at least 3 days prior to the microblading service.

Client Initials

AHA preparations should be undergone no less than 2 weeks before the treatment. Chemical, laser peel, and Retin A should not be performed/taken/applied 8 weeks before the procedure.

Client Initials

Topical Anesthetic Advice

Allergic reaction: can occur from any anesthetics used during 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.

Client Initials

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.

Client Initials

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 10-15 minutes, then carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetics, you can expect to experience some redness/ swelling that can last 1 - 3 days.

Client Initials

Approximate Healing Schedule for Microbladed EYEBROWS

You should always follow your post procedure/ after care advice for the best results. Day 1 Bold colour, dramatic appearance, tender, slight bleeding. Day 2 Eyebrows look very dark and appears thicker in texture. Day 3-4 Same as day 2 but a little lighter Day 5 Starting to itch. You may tap the skin with your finger tips only after washing your hands. Day 5-7 Flaky skin starts – peels from the outside edges first. Skin may be itchy. Day 7-10 Colour finishes flaking off. Color appears too light with missing spots. Feather strokes may appear “blurry”. 「 NOTE 」: The color will look weak and greyish. You may feel it is too light and that your skin did not take the colour well. Please be patient and color will darken as the skin heals. Day 14-21 Colour and definition returns, feathering starts to reappear and even out. Day 30 Healing is complete. All color healed within the skin. Eyebrows should look very natural and soft. 「 A second session may be mandatory 」 Color Refresh – To keep your new brows looking their best, it is recommended that you have a color refresh procedure every 12-18 months. I have read and fully understood the above information provided and any risks involved with the use of topical anesthetic. I, therefore, consent to the use of the anesthetics for the microblading (shading) procedure. I agree to follow pre-procedure advice closely.

I confirm that I have read and understood the FAQ.

Yes, I have had all my questions answered.

No, I am unclear and would like to ask additional questions.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND I ACCEPTFULL RESPONSIBILITY FOR THESE AND OR OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE MICROBLADING AND SHADING PROCEDURE. THE TREATMENT IS PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT, PRE-PROCEDURE FORM AND POST PROCEDURE GUIDELINES. I HEREBY AUTHORIZE TECHNICIAN CARRIE BUI TO PERFORM MICROBLADING AND SHADING PROCEDURE ON ME AT AESTHETICATION AND RELEASE AESTHETICATION AND ITS REPRESENTATIVES AND SUBSIDIARIES OF ALL CLAIMS FOR INJURY, SEEN OR UNSEEN, THAT MAY OCCUR AS A RESULT OF THIS PROCEDURE.

I confirm that I am NOT under the age of 18

How did you hear about us?

Please name person who referred you so we can personally thank them!

Thank you! I look forward to helping you achieve your brow goals!

Please read this form fully and fill in your information where requested.

AESTHETICATION

DEDICATION TO THE ART OF BEAUTY