Microblading Client Information Form

Client Information Form

Microblading & Permanent Cosmetics
St. Louis, MO
Contraindications for Microblading
Please review before continuing...

Generally, if you have any of the following, you may not be a good cantidate for Microblading or you may have to delay your appointment:
-Pregnant or nursing
-Undergoing Chemotherapy currently
(consult your doctor and receive a written release to receive treatment)
-Viral infections and/or diseases (you may need an Rx before treatment)
-Had a organ transplant
-Skin irritations near the treated area (rashes, sunburn, active acne, etc.)
-Sick (cold, flu, fever, taking antibiotics)

Please email, text, or call if you have any questions.

Feel free to fill out the online consultation form if you are unsure about any of these or if you are currently sick (like a common cold) and will be better soon. We will contact you soon after your application is completed.

If you have any questions please contact
inkedaestheticsUS@gmail.com
Welcome!

In order for us to determine if you are an ideal candidate for Microblading, we will need some information from you. Please answer the following questions below and attach a photo of the area you are looking to have treated or your face in your return message. Thank you in advance.
Attach a makeup-free photo of the area being treated or a close up of your face.*

Browse Files
Please attach a photo of your face. Make sure you are makeup free and the photo is taken in a well-lit area. We will inform you if you need to take another photo. Thank you for your patience and cooperation. We will notify you shortly if you are a candidate for this procedure. If you do not attach a photo, it may prolong the scheduling process Cancelof
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
How were you referred?*
If it was a friend, please tell us who so we can thank them!
Have you ever had Microblading or Permanent Makeup before?*

YesNo
If yes, when, where and what kind?
What area(s) are you looking to have treated? (select all that apply)*

Microblading BrowsPowder- Filled BrowsEyelinerEyelash EnhancementLip LinerLip Blushing (Full Lip Color)
Consent and Release Agreement

Microblading:

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 do not hesitate to ask. After your form is submitted, you will be contacted to schedule your appointment and to answer any additional questions you may have.

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

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

All instruments that enter the skin or come into 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 the healing is completed.

Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-60%, leaving a softer and more natural look. The pigment is semi-permanent and will fade over time. Additional touch-ups are likely needed within 6 months to 2 years.

Permanent Cosmetics:

This is an informed consent designed to give information needed to make an educated choice to undergo a permanent cosmetic application. If you have questions, please don’t hesitate to ask. All instruments that enter the skin or come in contact with body fluids are sealed and properly sterilized before use and disposed of after use. Cross contamination guidelines are strictly adhered to.

Although permanent cosmetic tattooing is effective in most cases, there is no guarantee that can be made that a specific client will benefit from the procedure.

Permanent Cosmetic Tattooing is the process of inserting pigment into the dermal layer of the skin. Generally, results are excellent and clients are thrilled with their new, enhanced look. However, it is important to have realistic expectations and not every client may achieve a perfect result. This can be but is not always due to poor healing, medical conditions, or not following instructions.

Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-50%, leaving a softer and more natural look. The pigment is considered permanent but will fade over time. (Generally 3-6 years) Additional touch-ups are likely needed within that time period to keep the color looking fresh.
Initial below with your finger or computer cursor to verify that you have read and comprehend the "Consent and Release Agreement" or have had read to you. By initialing, you are agreeing to a virtual eSign. Initial below to confirm your eSign*

Clear
Yes, I understand and this is my e-sign
Medical & Skin History

Please answer the following questions to the best of your ability. These questions are about your skin and your medical history...
Please list any allergies you have:*
If none, type "none"
Please list any prescribed medication(s) or over the counter vitamins/ supplement(s) you are currently taking: *
If none, type "none"
Are you or have you taken Accutane in the last 6 months?*

YesNo
Are you using Skin Care containing Retin-A, Retinols, or Exfoliating ingredients:*

YesNoUnsure
What is your current skincare routine? AM/PM*
Explain what products you use morning and night- we want to get an idea of the current condition of your skin.
Do you receive Chemical Peels or Facial Laser Treatments? If yes, when was your last treatment and what kind?*
mild, moderate, medical... did you peel, etc.
Are you currently under the care of an esthetician, plastic surgeon, or medical spa? (past 6 months)*

YesNo
Have you had facial surgery or recent trauma? If yes, please explain...*
Have you had facial surgery or recent trauma? If yes, please explain...
Have you had Botox or Dermal Fillers? *** If yes, when/ what treatment?*
If you have not, simply put "none"
Do you have alopecia or trichotillomania (Compulsive pulling of hair)?*

YesNo
Do you have eczema or dermatitis in or around the brow area?*

YesNo
How would you rate your skin?*

NormalCombinationOilySeverely OilyDry
Do you tan frequently? (being in the sun often or tanning bed)*

YesNo
Do you exercise frequently? (weekly)*

YesNo
Have you had chemo or radiation in the last 6 months? If so, you may have compromised immune system and need to consult your physician before treatment.*

YesNo
History of MRSA?*

YesNo
History of Diabetes?*

YesNo
History of Hepatitis A, B, C.... if yes, please explain*
If none, type "none"
History of alcoholism? NOTE: please do not drink alcohol 24 hours before receiving a treatment!*

YesNo
Smoker? Note: smoking can slow the healing process so you will want to avoid smoking throughout the healing process.*

YesNo
Currently Pregnant or Breastfeeding*

YesNo
Do you have an autoimmune disorder? If yes, please explain...*
If none, type "none"
Taking blood thinners? (Aspirin, Ibuprofen, Alcohol Daily, Cloumadin, Fish Oil, etc.) NOTE: You will need do avoid blood thinners 24-48 hours before treatment. This includes multi-vitamins.

YesNo
Initial below with your finger or computer cursor to verify that you have answered and understand the "Medical & Skin History" to the best of your knowledge. By initialing, you are agreeing to a virtual eSign. Initial below to confirm your eSign.*

Clear
Photography Release Consent

We would your permission to use these photos for for anyone that may be interested in having a treatment with Inked Aesthetics in the future. For example: portfolios, online and print ads, etc. Your consent is necessary regarding this. Please indicate if you would like your photos used or not used in advertising.
I consent to having my photo taken pre and post treatment:*

YesNo
You may use my photos to show potential clients within the office:*

YesNo
You may use my photos to show potential clients on social media and in advertising:

YesNo
You may use my photos and show my face:

YesNo
ou may use my photos and show my face...

Yes! You may show my face.No. No one can see my photos.Yes! Onle if my identity is concealed.Unsure, we can talk about it.
Special requests, remarks, concerns...
Initial below with your finger or computer cursor to verify that you have answered and understood the "Photography Release Consent" to the best of your knowledge. By initialing, you are agreeing to a virtual eSign. Initial below to confirm your eSign

Clear
Cancellation Policy & Scheduling
Your appointments are reserved especially for you. We value your business and ask that you respect our scheduling policies. Should you need to cancel or reschedule, please notify us at least 24 hours in advance.

Scheduling Your Appointment

A $200 deposit is required at the time of scheduling your appointment unless otherwise stated. The remainder of your service can be paid at the time of your appointment or made through payment plans offered through Inked Aesthetics or it's affiliates. $100 of your original deposit is non-refundable if your appointment is cancelled within 24 hours of the scheduled date.

The remainder of your balance is typically made in 2 (two) $200 increments unless otherwise specified- one at the time of your appoitment and the other at the time of your 4 week touch up. If you fail to make your touch up appointment 4-6 weeks after your initial appointment, you are still responsible for the remainder of your balance and will be charged to your card on file. Agreeing to these terms holds you responsible for this financial responsibility.

Late Arrival
Please arrive to your appointment at least 5-10 minutes prior to the scheduled time. All appointments have a designated time allotted. Early arrival allows for a relaxed and unhurried experience. If you are going to be late, please give us a call. If late arrival is inevitable, your service(s) may have to be rescheduled. We understandthings happen, but in the event that our schedules are tight, we want to make sure we can accomodate everyone that has a scheduled appointment if you are running begind.

Cancellations
Any cancellations with less than 24 hours’ notice for Initial Microblading procedures are subject to a cancellation fee amounting to your deposit of $200. Please understand that it is very difficult to fill a 2-hour appointment slot in less than 24 hours' notice and we have reserved that spot specifically for you.

No-Shows
Clients who miss their appointments without giving any prior notification will be charged the full amount of their deposit.

Repeat No Shows and Cancellations will result in a credit card being put on file and charged 50% of the services price prior to the appointment time. The remainder of the appointment balance will be due at the time of service.

A 4-week touch up is included in your Microblading service. If you are unable to make this appointment and do not notify Inked Aesthetics you are subject to a fee amounting to $80. This is a non-negotiable visit to ensure the success of your treatment and should be scheduled within 4-8 weeks of your initial treatment otherwise the pigment may not hold.

This policy applies to any complimentary touch up treatments thereafter.

Thank You!
When you schedule your appointment with us, you are agreeing to these policies. Please understand we reserve a staff member, a room and equipment just for you. We thank you for your cooperation and understanding and look forward to seeing you!

Per the request of my clients...
We accepts gratities in the form of cash, check, or Venmo (phone app). Gratuities are not expected but always appreciated.
Authenticate Signature with your Finger or Cursor. This indicates that you have read and understood the "Cancellation Policy and Scheduling". This signature also indicates that this form was filled out entirely by you with no help or influence and that you agree to all terms noted

Clear
Should be Empty:

Client Information Form

St. Louis, MO

Welcome!

Medical & Skin History