MICROBLADING CONSENT FORM

Please fill out the following form to help us understand your treatment profile.

First name

Date of Birth required

Last name

Phone

Email Address

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Are you currently trying to get pregnant, pregnant or breastfeeding?

Yes

Do you have a history of keloids or hypertrophic scarring?

Yes

Do you have any allergies (including latex, lidocaine, or tattoo ink)?

Yes

If yes, please specify:

Are you currently taking any medications, including blood thinners or antibiotics?

Yes

If yes, please specify:

Do you have any conditions such as diabetes, epilepsy, or autoimmune disorders?

Yes

If yes, please specify:

Have you had any previous cosmetic tattoos or microblading?

Yes

If yes, please specify:

Do you have a dermatologist diagnosed skin condition?

Yes

If yes, please specify:

Current medications (Dermatologist Rx)

Are you currently using any skincare products containing Retin-A, Accutane, or other strong exfoliants?

Yes

If yes, please specify:

Last date product used:

Last Retinol use:

Recent Botox/Fillers

If "other", please specify:

MICROBLADING INFORMATION AND CONSENT: I acknowledge that I understand the following information: Procedure Explanation: Microblading is a semi-permanent cosmetic procedure that involves the use of a hand tool to deposit pigment into the upper dermal layer of the skin, creating the appearance of fuller, more defined eyebrows. Initial Results: The results of the treatment will appear darker and more defined immediately after the procedure. Over the course of 7-10 days, the color may lighten as the skin heals and the pigment sets. Healing and Aftercare: It is essential to follow aftercare instructions to ensure proper healing and optimal results. Failure to follow these instructions may result in pigment loss, infection, or scarring. Touch-Ups: A touch-up session may be required within 4-8 weeks after the initial procedure to perfect the results. This touch-up is not included in the initial procedure price unless otherwise stated.

PHOTO AND VIDEO RELEASE: I give permission for Skin Divinity by Jennai to take photographs and videos of my treatment and results. I understand that these images may be used for marketing and promotional purposes, including social media, website content, and print materials. I understand that my identity will not be disclosed without my explicit consent, and that these images will be used to showcase the quality and effectiveness of the treatments offered by Skin Divinity by Jennai.

BY SIGNING THIS CONSENT FORM, I ACKNOWLEDGE THAT: I have been informed of the nature, risks, and potential complications of microblading, including but not limited to infection, allergic reaction, and dissatisfaction with the results. I understand that the results of microblading are semi-permanent and may fade over time, requiring future touch-up sessions to maintain the desired appearance. I understand that my skin type, lifestyle, and adherence to aftercare instructions can affect the final results of the treatment. I agree to follow the recommended aftercare instructions to promote healing and prevent infection or complications. I have disclosed all relevant medical information, including allergies, medications, and health conditions that could affect the outcome of the treatment. I release Skin Divinity by Jennai and its estheticians from any liability related to the microblading procedure and its outcomes, both immediate and long-term.

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