Microblading & Semi-permanent Makeup Services

Name *

First Name

Last Name

Date of Birth *

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DD

YYYY

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, permanent makeup, or eyebrow tattoos? *

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, Hepatitis B or C)

Allergies to lidocaine, epinephrine, or numbing agents)

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 near the brow area in the last four weeks? *

Yes

No

9. Do you have any skin sensitivities or conditions that affect your eyebrow area? *

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

Today's Date *

MM

DD

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