Please fill out all of the forms below before your microblading appointment.

 

Medical History

Name *
Name
Address *
Address
Phone *
Phone
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
Do you have or previously had any of the following *
Check all that apply
Date of Last Botox Treatment
Date of Last Botox Treatment
Date of Last Chemical Peel Treatment
Date of Last Chemical Peel Treatment
I agree that all the above information is true and accurate to the best of my knowledge. *
 

Service Consent

Statement of Consent and Recitals: Please read and check all boxes

Name *
Name
Checkbox *
Please be sure to read and check all of the boxes before submitting form
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 authorize Nicole Lee Kircher, as my Eyebrow Microblading technician at Copacetic Skin and Soul, to perform on my body the Microblading procedure desired today. *
 

POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS

Pain

There can be pain even after the topical anesthetic has been used. Anesthetics 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 our faces ARE NOT naturally 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.

Anesthetics

If necessary, topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform the artist now.

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 cosmetics.

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

Name *
Name
Consent and release for procedures performed: *
 

PHOTOGRAPHY RELEASE CONSENT

The artist and Copacetic Beauty Lounge 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 check a box and indicate with your form submission if you would like your photos used or not used in advertising. *
Name *
Name
Date *
Date
Phone *
Phone