Healthcare Microblading Consent Form

Healthcare Microblading Consent Form

Client Name:   Date of Birth:

Patient Information

Insurance Information

Medical History

Current Medications:

Allergies (medication, latex, pigments, topical anesthetics):

Check any of the following that apply:

Diabetes
Bleeding or clotting disorder
Immunocompromised or on immunosuppressive therapy
History of keloid or hypertrophic scarring
Heart disease / pacemaker
Pregnant or breastfeeding
Recent chemical peel, laser, or intense exfoliation in treatment area

Procedure Description

Microblading is a semi-permanent pigmentation procedure in which fine manual strokes are deposited into the superficial dermis to simulate eyebrow hair. A topical anesthetic may be applied for comfort. Pigment color and stroke pattern will be selected in consultation with the client. Multiple sessions and periodic touch-ups may be required to achieve and maintain desired results.

Risks, Complications, and Acknowledgements

I understand and accept that complications, although uncommon, can occur. These include but are not limited to: infection, allergic reaction to pigments or topical agents, scarring, pigment migration, color change or fading, asymmetry, need for additional corrective procedures, and poor healing. Results cannot be guaranteed. I acknowledge that pigments may fade or change tone over time and that future touch-ups are not included unless specified.

I understand that if I experience signs of infection, unusual pain, prolonged redness, or adverse reaction I must contact the clinic and/or seek medical attention. I have disclosed all known medical conditions, allergies, and current medications which may affect healing.

Alternatives and Benefits

Alternatives to microblading include makeup, eyebrow tinting, tattooing by other methods, or no treatment. Potential benefit is improved brow definition and appearance. I understand that individual results vary.

Pre-Procedure Instructions

Avoid blood-thinning medications and supplements (aspirin, ibuprofen, fish oil, vitamin E, certain herbal supplements) unless approved by your physician. Do not consume alcohol or caffeine 24 hours prior. Avoid Botox, fillers, chemical peels, laser resurfacing, or other aggressive treatments to the eyebrow area for the recommended interval before treatment. Notify the technician of any active cold sores, infections, or skin conditions in the treatment area.

Post-Procedure Care

Follow aftercare instructions precisely to reduce risk of infection or pigment loss. Expect initial darkening and scabbing followed by pigment settling. Avoid submerging treated area in water, heavy sweating, sauna, or direct sun exposure during healing. Touch-ups are typically required at 6–8 weeks for optimal retention.

Consent for Topical Anesthetic and Patch Test

I consent to the application of topical anesthetic agents as part of the procedure. I acknowledge that topical anesthetics carry risks including allergic reaction and skin irritation. If a patch test is recommended, I consent to a patch test prior to the full procedure.

Patch Test Performed: Yes   Date of Patch Test:

Photography and Records

I authorize clinical photography for medical records and treatment planning. Photographs may be used for educational purposes within the practice provided my identity remains confidential unless I give separate written permission for public use.

Consent to Photography: Yes   Consent to Use in Marketing/Publication: No

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the practice's privacy practices and understand how my health information related to this procedure may be used and disclosed for treatment, payment, and healthcare operations. I authorize release of information necessary to process my claim with my insurance carrier if applicable.

HIPAA Acknowledgment: I acknowledge and accept

Authorization and Certification

By signing below I certify that I have read and understand this consent form; that the procedure, risks, benefits, alternatives, and post-procedure care have been explained to me; and that all of my questions have been answered. I confirm that the information I provided on this form is complete and accurate to the best of my knowledge.

I understand that I may withdraw my consent at any time prior to the procedure. This authorization will remain in effect until the date specified below or until revoked in writing.

I certify under penalty of perjury that the above information is true and complete.

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