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Cosmetic Tattooing and Microblading Client Consultation and Consent
Please fill out this form carefully and submit it before your appointment.
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1
Name
*
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First Name
Last Name
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2
Date of Birth
*
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Date
Year
Month
Day
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3
Date
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Date
Month
Day
Year
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4
Email
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example@example.com
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5
Phone Number
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Area Code
Phone Number
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6
Medical Consultation
*
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Are you currently on any medication? Some medications may affect your healing and colour outcome. They may include medications for HRT (Hormone Therapy) , Depression, Diabetic and Immune Diseases.
Yes
No
Other
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7
Skin Type
*
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How would you describe your skin type?
Oily
Dry
Combination
Sensitive
Oily with Acne
Dry and sensitive
Other
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8
Have you previously had any eyebrow cosmetic tattooing?
*
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Yes
No
Other
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9
When was the last time you had your eyebrows Tattooed or Microbladed?
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10
How do you describe the old tattooed brows now?
Too light
Too dark
Spotted
Different shape
I am happy with the shape and color and would like to enhance the look
N/A
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11
Are you prone to Post Inflammatory Hyperpigmentation or Acquired Melanosis?
*
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Yes
No
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12
Do you develop keloid? (The scar rises after an injury or condition has healed, such as a surgical incision or acne.)
*
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Yes
No
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13
Do you have any of the following infectious skin conditions?
*
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Select 'None' if you did not have any of the following infectious skin conditions.
None
Boils/carbuncles
Ringworm
Fungal skin infection
Impetigo
Erysipelas
Scabies
Other
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14
Do you currently have any of the following skin conditions? Do you currently have any of the following skin conditions on your face, on or around the eyebrows?
*
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Select 'None' if you did not have any of the following skin condition.
None
Acne
Eczema
Skin cancer scarring
Dermatitis
Rash
Cyst
Dilated capillaries
Rosacea or coupe-rosé skin
Psoriasis
Sunburn bruising
climate related skin damage
benign or malignant tumours
allergic reaction (hives etc)
Other
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15
Do you have any of the following medical conditions or blood diseases?
*
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Select 'None' if you did not have any of the following medical condition.
None
Heart disease
Epilepsy
Kidney problems
Diabetes
Pacemaker
Cancer
Thrombosis
Low or high blood pressure
Haemophilia
Blood disease/condition
Hepatitis
Anaemia
Aids
Any blood clotting problems
Other
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16
Are you taking any prescribed medication at present that could thin blood or prevent skin healing well such as but not limited to anti-histamines, blood pressure pills, pain killers, etc?
*
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If you are taking any such medication, you will need to get your doctors' approval to not take your medication for 3 days prior to the appointment and 3 days after the appointment. We will need written medical approval for you prior to tattooing/microblading and we will ask you bring the written medical approval to the appointment.
Yes
No
Other
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17
Are currently taking acne medication or using Retin-A or Alpha Hydroxy skincare products?
*
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Yes
No
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18
Have you taken Roaccutane medication in the last 6 months?
*
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Yes
No
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19
Have you had Botox or dermal fillers on or around the eyebrows, eyes and forehead in the last 4 weeks?
*
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Yes
No
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20
Have you had any Electrolysis/Epilation/Laser or Chemical Exfoliation on your face in the last 4 weeks?
*
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Yes
No
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21
Are you pregnant or breast feeding?
*
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Yes
No
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22
Have you ever had an adverse reaction to numbing cream, pain killers or aesthetic?
*
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Yes
No
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23
Do you have allergic to anything?
*
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Yes
No
Other
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24
Anything else that you feel we should be aware of that or you feel could affect the actual treatment and process of cosmetic tattooing/microblading or the result, for instance; slowing skin to heal?
*
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Yes
No
Other
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25
Informed Consent for Cosmetic Tattooing Treatment Please read this consent form and sign to indicate you understand and accept the information contained herein.
*
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The information I have given is correct to the best of my knowledge and I have not withheld any unknown medical state or condition. I will inform the cosmetic tattooist before treatment if there has been any change (for example; medications taken) I confirm that I am over 18 years of age. I understand that microblading and cosmetic tattooing is the process of imbedding ink into the skin with the use of a tattoo needle or specialist micro-blade to enhance features on the face. I am aware of that I cannot change the shape or remove the tattoo/microblading from the treatment area later, if I am not happy with that. I understand the results from this treatment vary considerably and a small percentage of people will not respond satisfactory to treatment. I am aware that more than 1 touch up treatment may be necessary for best results and there is a cost for the second perfecting session following up treatment. I understand that there may be possible side effects such as reddening, bruising, swelling, The topical anesthetic used may contain Lignocaine and Tetracaine Prilocaine. I am responsible for the "at home after care" which may have risk of infection or fading. I consent to before and after photos of this procedure I understand that there are no refunds given I consent to do any kind of cosmetic tattooing on my old tattoo although I am aware that it might show reaction/ allergy to previous pigments. l accept all consequences. The information I have given is correct to the best of my knowledge and I have not withheld any unknown medical state or condition. I will inform the cosmetic tattooist before treatment if there has been any change (for example; medications taken) I confirm that I am over 18 years of age. I understand that microblading and cosmetic tattooing is the process of imbedding ink into the skin with the use of a tattoo needle or specialist micro-blade to enhance features on the face. I am aware of that I cannot change the shape or remove the tattoo/microblading from the treatment area later, if I am not happy with that. I understand the results from this treatment vary considerably and a small percentage of people will not respond satisfactory to treatment. I am aware that more than 1 touch up treatment may be necessary for best results and there is a cost for the second perfecting session following up treatment. I understand that there may be possible side effects such as reddening, bruising, swelling, The topical anesthetic used may contain Lignocaine and Tetracaine Prilocaine. I am responsible for the "at home after care" which may have risk of infection or fading. I consent to before and after photos of this procedure I understand that there are no refunds given I consent to do any kind of cosmetic tattooing on my old tattoo although I am aware that it might show reaction/ allergy to previous pigments. l accept all consequences. I have been given opportunity to discuss color and shape and I am happy with the choices I have made.
I understand and agree to the terms mentioned above
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26
I further understand that Ira Bale Brows is relying on the information provided above.
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