Pre-Procedure Acknowledgment Form

-Microblading & Semi-Permanent Makeup-


Thank you for your interest in scheduling a Microblading or Semi-Permanent Makeup appointment at Parlour59. Please take a moment to read, sign and submit this form before calling to schedule an appointment. By inputting your name, you are signifying you understand the advice and precautions you and Parlour59 should take when having these procedures done. After signing your name, this form will be sent to Parlour59 and kept on file. Any field with an asterisk (*) is required and this form will not submit unless every required field is answered.

Please Note: You must submit this form only once and will be asked by Parlour59 if you have before being allowed to schedule for a procedure.


Pre-Procedure Guidelines

A Microblading procedure normally requires multiple treatment sessions. For best results, clients will be required to return for at least one re-touch appointment. This will take place 6 weeks after the initial procedure. Please be aware that color intensity will be significantly darker and sharper immediately and a few days after the initial procedure, but the color will reduce by 30-50% depending on skin type.

  • Although numbing cream and second layer numbing spray is used during the procedure, sensitivity or discomfort may still be felt. Skin may be red and/or swollen after the procedure.

  • Please do not drink alcohol 24 hours prior to the treatment.

  • Unless medically necessary, please avoid taking things that thin the blood like fish oils, herbals, Vitamin E, aspirins.

  • Where possible, try to avoid the following herbs and spices prior to your appointment: Black pepper, Cardamom, any member of the Zingiberaceae (Ginger) family, Cayenne, Cinnamon, Garlic, Horseradish, Mustard.

  • A patch test can be performed, unless waived by client. It is the client’s responsibility to schedule this at least 2 weeks prior to the procedure.

  • Please do not shape or wax your brows before the procedure. Your technician will shape brows during the procedure.

  • No electrolysis for at least 5 days before the procedure.

  • Botox, AHA products and Retinoid should be avoided for 2 weeks prior to the procedure.

  • Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure.

  • Chemical and laser peels should be avoided no less than 6 weeks prior to procedure.

  • Patients prone to cold sores/fever blisters should take an anti-viral prior to treatment.

  • Hormone therapies can affect pigmentation and/or cause sensitivity.

  • Discontinue use of any brow-growth serums like Latisse or Lash Boost as it can cause sensitivity and/or affect pigment.

Topical Anesthetic Advice

Allergic reaction can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.

NUMBNESS

We cannot accept responsibility if the area to be treated does not respond to the numbing cream. Everyone is different according to skin type. Some clients report the area to be completely numb, while others may experience some discomfort.

PROCEDURE

For microblading procedure, a numbing cream/gel is used. The products are formulated to be perfectly safe and can be purchased over the counter from any pharmacy/chemist. The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness/swelling that can last 1-4 days. You should always follow your post procedure advice and after care for the best results.

Contraindications for Microblading:

  • Liver disease—high risk of infection

  • Pregnancy/Nursing

  • Compromised skin near brow area

  • Chemotherapy/Radiation

  • Skin conditions like psoriasis, dermatitis, etc. near the brow area

  • The following medical conditions require a note from your doctor giving consent

  • Diabetes Type 1 and 2, high blood pressure, auto-immune disease, thyroid / Graves’ disease Any other medical condition that causes slow healing or a high risk of infection

SIGNATURE
Todays Date *
Todays Date