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AM low W CLIENT CONSULTATION MEDICAL 'EVER LR ST Ii HEALTH FORM FOR MICROBLADING BROWS Name: Surname: DOB: Age: Address: Post Code: Contact No: Email: Occupation: List any medications you have been taking in the past 6 months Have you received chemotherapy or radiation in the past year? Have you ever had an allergic reaction to one of the following?Lanolin E] Latex rubber E Vaseline E Medication Metals F1 Hair F_�Dyes 17 Foods Lidocaine 1:1 Paints EJ Crayons Glycerine Other allergies: Have you ever had one of the following?Retain A within last 2 weeks❑Anaemia sensitivity to cosmetics❑Prolonged bleeding E] Trichotilomania 1:1Low Blood Pressure E]Artificial HeartValves E]Diabetes Haemophilia Fainting spells or dizziness o High blood pressure El Liver disease D Circulatory Problems FlEpilepsy F-1 Tumours,growths or cysts Thyroid disturbances FIHIV F] Hair loss ElHepatitis FICancer F] Chemical or laser peel within 6 weeks E Alopecia El AHA preparations in the last 2 weeks 1:1 Fat injections,Botox injections,Collagen injections E Hypertrophic scars 1-71 Keloid Scars El Healing problems El Do you scar easily? L1 Do you bruise or bleed easily? a Are you currently pregnant or nursing? a What are the main concerns relating your eyebrows? What would you like to improve?Think about shape,colour,density,thickness of your perfect brow FOR THERAPIST USE: Note pigments,blades,techniques to be used for this client Please read the following statements carefully: Microblading is a way of cosmetic tattooing. Re-touch procedures may be required.A healing period of 4 weeks is required before a touch up procedure can be performed. On a rare occasion,the pigment may migrate under the skin. Procedure of microblading may be slightly uncomfortable. The pigments will fade. Immediately after the procedure, the pigment can appear 30-50%darker than the desired result.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 anaesthetic can occur.Permanent cosmetics cannot be applied to pregnant women or nursing mothers. Permanent cosmetics cannot be applied to any person 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 scaring may occur,but is extremely rare. I have received an after care leaflet and I'm fully aware of the after care procedures. I have fully understood the information provided above. I can confirm that all of the information provided by me,is correct and truthful. Client's Full Name: Client's signature: Date: Technician's Full Name Client's signature: Date: Please continue to general consent and procedure permit form on reverse nci,iinn C: r )01 r.