Microblading & Semi-permanent Makeup Services

Name *

First Name

Last Name

Date of Birth *

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DD

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Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1. Are you over the age of 18? *

Yes

No

2. Have you ever had previous microblading, eyebrow tattooing, or permanent makeup? *

Yes (Please specify when and by whom in the box below.)

No

3. Are you currently pregnant or nursing? *

Yes

No

Not applicable

4. Do you have natural eyebrow hair? *

Yes

No

5. Do you have any of the following medical conditions? *

Check all that apply.

Diabetes

Epilepsy or seizures

Bleeding disorders

Skin disorders (e.g., eczema, psoriasis)

Keloid or hypertrophic scarring

Autoimmune disorders (e.g., lupus, rheumatoid arthritis)

Bloodborne diseases (e.g., HIV, HSV, Hepatitis B or C)

Allergies to lidocaine, epinephrine, or numbing agents)

History of cold sores or shingles

None of the above

6. Do you have any allergies? *

Yes (Please specify in the box below.)

No

Do you take any blood-thinning medications, aspirin, or supplements (e.g., fish oil)? *

Yes (Please specify in the box below.)

No

8. Have you had Botox or dermal fillers in the face in the last four weeks? *

Yes

No

9. Do you have any skin sensitivities or conditions that affect areas of the face? *

Including but not limited to eczema, psoriasis, rosacea

Yes (Please describe in the box below.)

No

10. Do you have any major medical procedures or surgeries planned in the next 6-12 months? *

Yes (Please describe in the box below.)

No

11. Do you tan or use tanning beds? *

Yes

No

12. Have you used any retinol, glycolic acid, or acne treatments near the brow area in the past 30 days? *

Yes

No

1. I understand that microblading is a semi-permanent cosmetic tattoo and results may vary based on skin type, lifestyle, and adherence to aftercare instructions. *

Yes

No

2. I understand that my skin must be free of active skin conditions, cuts, infections, or irritations on the brow area for the procedure. *

Yes

No

3. I understand that it is my responsibility to inform Blushed Beauty Bar of any changes to my health or medications prior to the appointment. *

Yes

No

4. I understand the risks associated with microblading, including possible allergic reactions, swelling, redness, and uneven results, and I consent to the procedure. *

Yes

No

1. What service(s) are you interested in? *

Microblading Eyebrows

Eyeliner

Lip Blushing

Tattoo Removal

Scalp Micropigmentation

Medical Tattooing

Today's Date *

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