Micropigmentation - Mary Clinic

Micropigmentation Consent Form

Step 1 of 13

Name(Required)

First Last

Date of Brith(Required)

Day

Month

Year

If You Complete the From on Behalf(Required)

First Last

Relation To Client(Required)

Contact Number (Mobile)(Required)

Contact Number (Land Line)

Address & Postal Code(Required)

FirstLine Second Line City Post Code

Occupation(Required)

Do You Have WhatsApp?(Required)

Yes

Best Way to Contact You?(Required)

Call

SMS

Please read and complete this form carefully.

Please indicate your answer by checking one box per question and provide detail where appropriate.

To the client:

You have the right to be informed about the procedure(s) to be administered, including benefits, risks, and potential side-effects, so that you can decide whether to proceed. You are encouraged to ask any questions you may have and to consult with a therapist if you have additional questions.

1.Are you pregnant or breastfeeding?(Required)

Yes

Please Explain:

(During the pregnancy and breastfeeding you are not allowed to do any micropigmentation treatment.)

2.Are you prone to keloid scarring?(Required)

Yes

3.Are you currently or have you taken any medication containing Isotretinoin (e.g. Roaccutane) within the past 12 months?(Required)

Yes

Please Explain:

4.Do you have any active infections-viral, fungal, bacterial?(Required)

Yes

Please Explain:

5.Do you have any rashes or moles on the treatment area?(Required)

Yes

Please Explain:

6.Have you ever had skin cancer?(Required)

Yes

Please Explain:

7.Do you have any skin disease or condition such as Eczema?(Required)

Yes

Please Explain:

8.Do you have lupus?(Required)

Yes

Please Explain:

9.Do you have any skin related autoimmune disorders?(Required)

Yes

Please Explain:

10.Do you have any active acne in your treatment area?(Required)

Yes

Please Explain:

11.Do you have any conditions that could affect your immune system e.g. Hepatitis C Virus (HBC), Hepatitis B Virus (HBC), AIDS, HIV infection?(Required)

Yes

Please Explain:

12.Are you currently on any form of immune suppressant therapy that may cause delayed healing e.g. Chemotherapy, radiation?(Required)

Yes

Please Explain when was your last Session:

(To do any needling treatment should pass 6 weeks from your last session.)

13.Do you have any neurological disorders such as Epilepsy, Bell’s palsy, MS, Chorea or Myasthenia Gravis?(Required)

Yes

Please Explain:

14.Do you have any allergies such as latex, lidocaine, antibiotics, food, drugs / substances?(Required)

Yes

Please list:

15.Are you allergic or sensitive to any local or topical anaesthetic (including dental anaesthetics)?(Required)

Yes

Please Explain:

16.Are you sensitive to any regular makeup, hair dyes or any other dyes?(Required)

Yes

Please Explain:

17.Do you have any Asthma or other allergic disease?(Required)

Yes

Please Explain:

18.Do you carry a warning card, Epi pen, had anaphylaxis reaction?(Required)

Yes

Please Explain:

19.Have you ever had a cold sore?(Required)

Yes

Please contact to your physician for preventative prescription capsule to prevent a cold sore.

20.Do you have or have you ever had any heart or blood pressure problems?(Required)

Yes

Please Explain:

21.Do you have blood-borne disease?

Yes

Please Explain:

22.Do you have a stroke or any other blood pressure problems?(Required)

Yes

Please Explain:

23.Do you have Angina, Murmur, Valve or other heart condition?(Required)

Yes

Please Explain:

24.Are you take any blood thinners, both prescription and over the counter?(Required)

Yes

Please Explain:

25.Are you currently taking any medication to treat the following, which may affect blood coagulation during the Microblading procedure?

Sleeping Pills

Blood Pressure Medication

Hormone Replacement

Antibiotics

Tranquilizers

Painkillers (Aspirin/Ibuprofen)

Fainting/Dizzy Spells

Diabetes

Cortisone (Inhaler/cream)

26.Are you currently taking any medication?(Required)

Yes

Please list any medication you have been taking in the last 6 months, both prescription and over the counter:

27.Do you have any neurological disorders such as Epilepsy, Bell’s palsy, MS, Chorea or Myasthenia Gravis?(Required)

Yes

Please Explain:

28.Do you have any endocrine disorders such as Diabetes or Thyroid?(Required)

Yes

Please Explain:

29.Do you have any chronic medical conditions?

Yes

Please Explain:

30.Have you had any cosmetic procedures such as dermal fillers, fillers, reconstruction?(Required)

Yes

Please List:(Required)

When

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

More than 1 year

31.Have you had any aesthetic procedures?(Required)

Yes

Choose

Laser

Skin exfoliation

Skin peeling

Dermabrasion

Gold wire

Ultrasound

other

When

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

More than 1 year

32.Have you had any aesthetic surgery such as liposuction, nose job, jaw, hair transplant, breast augmentation, etc.?

Yes

Please Specify

Less than 1 month

Less than 3 months

Less than 6 months

Less than 1 year

More than 1 year

33.Did those previous aesthetic procedures cause any undesirable reactions?(Required)

Yes

Please Specify:(Required)

34.Do you have an eye disease?(Required)

Yes

Please Explain:(Required)

35.Have you had healing problem after surgery or trauma?(Required)

Yes

Please Specify:(Required)

36.Do you have any recent vaccinations, cortisone injections or steroids?(Required)

Yes

Please Specify:

37.Do you use therapies/supplements such as St. John's Wort?(Required)

Yes

Please Specify:

Micropigmentation Post Procedure Instructions

Your skin will be temporarily sensitized after the treatment and you should adhere to the following instructions for the next five to seven days. This will help avoid infection and will allow time for the skin to recover.

Refrain from:

Touching the treated area
Using soaps, cleansers, creams or make-up on the treated area for 5 days
Facial treatments - including eyelash or eyebrow tinting or tweezing, electrolysis. waxing etc.
Any abrasive products, rough towels or similar
DO NOT TOUCH or PICK the small scabs that may appear after the treatment. Healing will take up to one week, and it is perfectly normal for the treated area to scab/flake. These scabs/flakes will fall off within a few days.
Taking hot baths, saunas, or any other heat treatments. The treated area should be kept as dry as possible.
Sunbathing, using sun beds or swimming
Using any form of bleach or depilatory products
Should an infection occur, seek medical attention
Expose the treated area to UV rays
Use make-up other than the recommended after care products
Going for any Laser or IPL treatments

Agreement(Required)

I understand that the therapist will recommend and craw the ideal shaped eyebrow however, I am free to change the shape as I desire and understand that the shape will be final and cannot be changed after the procedure.
I hereby deciare that I do not suffer from Keloid Scaring.
I hereby declare that I am not haemophiliac.
I hereby declare that I am not allergic to Iodine.
I hereby declare that I do not test positive for the HIV or Hepatitis Viruses
I hereby declare that I am not pregnant/breastfeeding
I hereby declare that I have had no Botox treatments for the past 28 days.
I hereby declare that I have had no Filler Injections for the past 3 months.
I hereby declare that I am not under treatment for Cancer/Radiation/ Chemotherapy
I hereby declare that I am aware there is NO GUARANTEE for the outcome of my procedure.
I hereby declare that I do NOT have any of the Medical Conditions that were mentioned in the above indemnity Form.
I hereby declare that I am under FULL UNDERSTANDING that the procedure is a Tattoo and a touch-up is VITAL at a reduced price.
I hereby declare that I am aware the full results will only be visible AFTER 6 WEEKS.
I authorize the use of my photographs taken by the technician to be used on social media and shown to potential clients.
I hereby declare that I have been informed, in detail about the 6D Microblading method and procedure which will be performed. I was informed that needles are used for the treatment to inject colour pigments into the upper layers of the skin.
I am aware that it is not possible to predict how durable and intensive the brow colour will be and that durability and colour intensity depend on age, skin type and environmental conditions of the treated person.
I am aware that the treatment with the pigmenting needles can cause skin irritation and minor inflammation of the skin which usually disappears within 24-36 hours.
I have been informed that the pigments will appear darker within the first 5 days.
I have been informed that the section of skin to be pigmented may be anesthetized/numbed with a surface anaesthetic.
I have been informed that medicines affect different individuals in different ways.
In some cases, side effects can occur such as allergic reactions.
I hereby declare that Aftercare procedures have been explained to me in detail and I have read the instructions given on this sheet. Furthermore, I understand the Post Procedure Instructions.

I agree to all the Conditions

I Understand that I am responsible for notifying the beauty therapist if any of the information should change before treatment.
I confirm that the information is true to be best of my knowledge. I have been fully informed about the expected results and effects of my treatment and agree to follow all aftercare advise provided by therapist. I acknowledge that all information is confidential and will be held on file for 7 years, being solely for the purpose and use of my therapist. I hereby give my consent to proceed with treatment.
I understand and agree that all services rendered are charged directly to me and I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.
Under fake not to make a claim against the therapist and salon and do hereby indemnify and hold the said business, its Owner and Employees harmless in respect of any claim or damage suffered by me in the consequence of undergoing the treatments procedure.

I agree to the Terms of Service

Printed Name(Required)

First Last

Guardian Printed Name(Required)

First Last

October 14, 2026

Unique ID

Client Signature(Required)

Guardian Signature(Required)

Where did you hear about the clinic?

Recommendation

Advert

Social media

Other

other

I would like to be notified of any upcoming offers or promotions:

YES! I love it!

No, Thank you

CAPTCHA