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Microblading Consultation & Consent Form
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Name
*
First
Last
Phone Number:
Emergency Contact:
Medical Disclosure
Please check all that apply:
Pregnant or Nursing
Diabetes
Autoimmune Disease
History of Keloids/Hypertrophic Scarring
Skin Conditions (eczema, psoriasis, rosacea)
Currently taking blood thinners, Accutane, or Retin-A
Botox or fillers in the brow area within the last 4 weeks
Allergies to lidocaine, pigments, or numbing agents
Previous Brow Tattoo / Microblading
Have you had previous microblading or permanent makeup?
Yes
No
If yes, date and provider:
Pre-Care Acknowledgment
By signing below, I confirm that:
I have not consumed alcohol, caffeine, aspirin, or blood thinners in the past 24 hours.
I understand sunburn, skin irritations, or active acne in the brow area may delay or
prevent treatment.
I will follow all pre- and post-care instructions provided by my technician.
I understand that:
Microblading is a semi-permanent tattoo process involving pigment implantation into the skin.
Results may vary depending on skin type, age, lifestyle, and aftercare.
Minor discomfort, redness, swelling, or scabbing is normal and may last a few days.
I may require a touch-up session 6–8 weeks after the initial appointment.
Photo Consent
YES, I give permission to Luxe Aesthetic Lab to take before and after photos of my brows.
These photos may be used for marketing, social media, and educational purposes.
NO, I do not consent to any photos being used publicly.
Release of Liability & Consent
By signing below, I confirm that:
I have read and understood all information provided.
I am of legal age (18+) and voluntarily consent to this microblading procedure.
I release the technician and Luxe Aesthetic Lab from all liability for any harm or injury
resulting from the procedure, except in the case of gross negligence.
Signature
Clear Signature
Date
Technician Signature
Clear Signature
Date
Submit