Microblading Treatment Questionnaire
Please fill out the below medical questionnaire, to provide a safe Microblading experience.
Your data are strictly confidential and visible only to your microblading artist.
We care about your privacy and information will not be saved online.
Thanks for your cooperation.
Date of Birth
Street Address Line 2
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
East Timor (Timor Timur)
Papua New Guinea
Saint Kitts and Nevis
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
Emergency Person Name
Emergency Person Phone
Are you taking any Medication?
If yes please write below:
Allergies to metals, food, etc.
If yes write below
Oily Skin ?
Difficulty numbing with dental work
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?
Keloid , cicatrization issues
You MUST be off Retin-A or Retinols for 4 month prior to your appointment and avoid using on or around the area for 30 days after. If used before 30 days, it can cause the pigments to fade prematurely.
Take medication before dental work
If Botox, Last treatment:
If Filler, last treatment :
Hepatitis A B C D
Abnormal Heart Condition
If Chemical Peel, Last treatment:
Brow Lash Tinting
Pregnant now or Breastfeeding now
Accutane or acne treatment
Tan by booth or salon
If Cancer, Year
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin
Taking other blood thinners write below
Tumors/ Growth/ Cysts
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc
Other medication allergies write below
Covid vaccination minimum two weeks before or after the treatment, as it might interfere with the treatment
I, as well as all household members, do not currently have, nor have experienced the following symptoms within the last 14 days: Fever Fatigue Dry Cough Difficulty Breathing And I ve not being exposed to any covid-19 case in the last 14 days.
Any diseases or disorders not listed.
If yes please write here:
Eyebrow Microblading and micro pigmentation Healing process. While every person is different and some heal more quickly or slowly than others, here’s generally what to expect. Temporary side effects from micropigmentation include but are not limited to: redness, swelling, puffiness, bruising, dry patches and tenderness. Day 1 -5 The eyebrows are approximately 20- 25% bolder and darker in width than they will be when healed. Don’t be concerned that your eyebrows initially appear darker and heavier in size than you desire. This is all part of the process You should expect to lose approximately 1/3 of the initial color during the healing process. In approximately six days it may appear too light. After about 10 days, the color will show more. It will appear softer when completely healed. I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS.
Post Procedure Care General Microblading (permanent makeup) procedures are affected by the „canvas“ (your skin) that they are performed on. Lifestyle, medications, smoking, metabolism, facial surgery and other procedures, and age of skin all contribute to fading. Though rare, infection is possible. If you see signs of infection such as persistent increased redness or swelling, fever, drainage, or oozing, contact your doctor immediately. When the area starts to flake, leave it. Do not pick, peel or pull on the skin. • Wash lighlty with cotton pads and water or clean with Phiwipes the area 30 min after the treatment and than every hour after the procedure then apply a very thin coat of aftercare ointment (provided to you by your technician) to the area as advised, do not over use the ointment as it can cause poor retention• Avoid sweating such as from vigorous exercise for at least one week post-procedure or until healing is complete. Keep your hands clean and avoid touching the affected area(s). Do not scrub or pick treated areas, Do not use peroxide or Neosporin on treated areas. Do not expose area to direct sun or to tanning beds, Avoid exposing the area excessive moisture or humidity, such as: facials, swimming, whirlpools (hot tubs), saunas, steam rooms, and steamy showers. • Avoid Retin-A, moisturizers, glycolic acids, exfoliants and anti-aging products at all times (not just during healing) on all micropigmented areas. These can cause pigments to fade and lighten prematurely. • Avoid tanning beds, sun, chlorine spas and pools, soap and chemicals (including skin cleansers, makeup removers, alpha hydroxyl creams, and tooth whitening toothpaste) near the treated area until healed. • Pigments will slowly fade overtime according to one’s metabolism, skin type, sun exposure, medication, facial surgery, and smoking. Schedule maintenance visits as needed to keep it looking fresh. • Periodic touch ups will ensure longer lasting results. Eyebrows • For the first 7 days, avoid soap or cleansing products. Wash only with water and pat dry with a clean, dry cloth. • Do not resume any method of eyebrow hair removal or coloration for at least two weeks. • Avoid eyebrow tinting within 2 weeks before or two weeks after the procedure.
I acknowledge it is not reasonably possible for the representatives and employees of this permanent makeup salon 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. We use only pigments approved by EU law.
I understand the permanent skin pigmentation procedure carries with it possible complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. I understand this is a tattoo process and therefore not a science but an art. I request the permanent skin pigmentation procedure(s) and accept the permanence of the procedure as well as the possible complications and consequences of the procedure(s).
I understand the taking of before and after photographs of said procedure(s) are required. Artist will ask for your permission only in case of public use .
There is a possibility of an allergic reaction to pigments. A patch test is advisable in case of previous allergies history however it does not ensure a client will not have an allergic reaction.
I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.
I have been quoted for the cost of today’s procedure and that cost is non refundable . I m informed that touch up is required and is included only if performed within 50 days.
I approve of the shape and design created by my Microblading provider and I give my consent to use Microblading tools to apply pigments into my skin in the eyebrow area and modify the look of my existing eyebrows.
I am over the age of 18, am not under the influence of drugs or alcohol .
I agree to release and forever discharge and hold harmless the Artist from any and all claims, damages or legal actions arising from or connected in any way with my permanent makeup , or the procedure and conduct used in my permanent makeup . Treatment is not refundable . I release and waive any current and future claims, demands, actions, causes of actions, suits, costs, liabilities, damages against my Microblading provider, for the right of privacy and publicity violation and invasion, intrusion of soltitude and seclusion, public disclosure of private facts, health record protection violations, false light, appropriation of the name or likeness, tort of defamation, commercial exploitation and other privacy related rights violations.
I give consent to be contacted via SMS text : email messages by the business, during business hours regarding but not limited to: important after-care information, special deals and promotions.
I agree that all the above information is true and accurate to the best of my knowledge.
If you wear contacts, you may want to bring your case or wear glasses. I will be stretching the skin on your eyelid area which may be uncomfortable with contacts in.
NIF (If avcailbale)
How did you know about us?
I authorize to receive text message appointment reminders, service surveys and other marketing messages to me on my provided cell phone number. I understand that I may reply with various commands to receive account information such as balances, future appointments, office location and other alerts. By accepting these terms, I agree that all individuals associated with my account may receive alerts referencing the account guarantor and/or dependents. Text message charges from my cell phone provider may apply.