Medical History Form

Welcome to your Medical History Form

Full Name
Address
Phone Number
Email
Date
Birthdate
Age
Emergency Contact Person
Emergency Contact's Number
Have you had any of the following?
History of MRSA
Botox.
Diabetes
Hepatitis A, B, C or D
Forehead/Brow Lift
Easy Bleeding
Facelift
Alcoholism
Abnormal Heart Condition
Take medication before edental work
Chemical Peel.
Pregnant now or breastfeeding now?
Brow/Lash Tinting
Autoimmune disorder
Oily Skin
Cancer.
Accutane or acne treatment
Chemotherapy/Radiation
Tan (booth or salon)
Tumours/Growth/Cysts
Difficulty numbing with dental work
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin, etc.
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzl, Alcohol, Carbopol, Lecithin, Propylene Glycol, Victamin E Acetate, Etc?
Allergies to metals, food, etc?
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl? Please list any medications you are taking.
By selecting "I agree" I confirm that all the above information is true and accurate to the best of my knowledge.
Consent and Release Agreement

This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow, Microblading, semi- permanent makeup application. If you have any questions, please don’t hesitate to ask.

Although 3D Eyebrow Microblading is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semipermanent, it is considered a permanent marking.

All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after use. Cross contamination guidelines are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual and advised to expect a Touch-Up after healing is completed.

Initially the colour will appear more vibrant or darker compared to the end result. Usually within 5-7 days the colour will fade 40-50%, soften and look more natural.

The pigment is semi-permanent and will fade over time. Additional TouchUps are likely needed within 6 months to 2 years.

Photography Release Consent


We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please select if you would like your photos used or not used in advertising.

Possible Risks, Hazards, or Complications


Pain: There can be pain even after the topical anaesthetic has been used. Anaesthetics work better on some people than on others.

Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See “After Care” sheet for instruction on care.

Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance.

Asymmetry: Every effort will be made to avoid asymmetry, but out faces our not symmetrical so adjustments may be needed during the follow-up session to correct any unevenness.

Excessive Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don’t bruise or swell at all.

MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI Technician of any tattoos or permanent.

Allergic Reaction: Although an allergy is unusual, there is always a possibility of an unknown allergy to the pigments and materials used during procedure.

The alternative to these possibilities is to use traditional cosmetic and NOT undergo the Semi-Permanent Eyebrow procedure.

By selecting "I agree" below you consent and release for procedures performed:

Statement of Consent and Recitals:


By selecting "I agree" you are confirming you have read and agree with the following: 
Aftercare instructions have been explained to me and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email you.

I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.

I understand that although the European technique performed correctly, is considered semi- permanent since it fades and exfoliates out with the skin over time, strokes and markings are considered permanent by nature and by the Health Department.

I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the colour and cause premature exfoliation of the pigment.

I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup.

I understand that successful colour saturation can NOT be guaranteed due to hidden scar tissue.

I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.

I accept the responsibility to explain to you by desire for specific colours, shape, and position for any procedure done today.

I understand that implanted pigment colour can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the colour with future applications and a touch-up session within 60 days.

I acknowledge that the proposed procedures(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor colour retention, hyperpigmentation, scarring, bleeding, & nerve damage.

I have been advised that a touch-up session is highly recommended to make any adjustments to shape, colour, and to fill any pigment that may have had poor retention. Touch- ups must be completed within 60 days of initial procedure.

I have been quoted the cost of today’s appointment, and the cost of the touch-up. Touch-ups must be completed within 60 days of initial procedure to be considered a touch-up price.
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorise the team at FabYouLash as my Eyebrow Microblading technician(s) to perform on my body the 3D Eyebrow Microstroking procedure desired today.