Machine Translated by Google

TOKEN DATE
ANAMNESIS

Name:

Date of birth: / / NIF;

Telephone:( ) Email:

Address:

Form of payment:

MICROBLADING
PRE-PROCEDURE EVALUATION MANUAL PIGMENT INDUCTION

Under medical treatment? Not Yes Specify:

Medications in use? Not Yes Specify:
Diabetic? Not Yes Specify:

Hypertension? Not Yes Specify:

Cancer history? Not Yes Specify:

Wound problems? Not Yes Specify:

Allergy to cosmetics? Not Yes Specify:

Sensitivity/allergy? Not Yes Specify:

Autoimmune disease? Not Yes Specify:
Skin disease? Not Yes Specify:

Recent surgery? Not Yes Specify:

Use of cosmetic acids? Not Yes Specify:

Do you diet? Not Yes Specify:

Cardiovascular problems? Not Yes Specify:

HIV? Not Yes Anemia? Not Yes

Hepatitis? Not Yes Pregnant? Not Yes

Contagious Infectious Diseases? Not Yes Breastfeeding? Not Yes

Are you menstruating? Not Yes Smoking? Not Yes

Alcoholism? Not Yes

PERSONAL CHARACTERISTICS

Skin type: Skin color:

By the: Eye color:

Phototype Subtom:
:

Comments:

Is there any problem you deem necessary to inform before the procedure? Not Yes

Specify:
Machine Translated by Google

PIGMENT
Pigment Brand:
Opening date: Expiration date:
Used colors:

BLADE
Needle/Blade used:

I am aware that I will perform eyebrow microblading with the professional:

The procedure and all the implications related to it were explained to me and I am aware of my psychological and health
conditions, thus leaving the professional exempt from any responsibility regarding the reactions that I may present. I declare
that I am informed about the difficulties of removing the procedure as well as the risk of allergic reactions arising from pigments
and materials or their organic rejection as a foreign body to the body. I am aware and confirm that the material that will be used
is disposable, as well as all hygiene standards are being followed correctly, according to the norms. Taking into account the
absorption of the pigment in each organism, and also the care that the client will have to take from the moment he chooses to
microblading or micropigmentation of eyebrows, studies prove the durability of an average of 8 months to 1 year, in this period
respecting all the indications of the micropigmentator, the pigment tends to lighten naturally over the months, but it will not
disappear definitively, so there is a need for maintenance during this period. The retouching should only be carried out after 30
days. For all retouching carried out, we will charge a fee of:____________________(charged only after the 3rd session)
referring to the material used. Retouching is considered up to the first two months, after this period we will carry out
MAINTENANCE, at the price of the current table The model/format of how the front design will look the professional designed
and showed how it would look, he erased and redid it until it was to my liking, guiding me which model would be best for me,
but prevailing the design that “I” chose, only micropigmenting after my authorization. If I regret the format, I am aware that it will
be a job with separate fees. I undertake to correctly follow the treatment, in case of non-attendance on the date set for the
touch-up, the micropigmenter will be exempt from responsibility for the work and I am aware of this. PAY ATTENTION TO THE
RETOUCH DATE. In case of intercurrences and unable to attend the service, please call and cancel the appointment within a
period of at least 24 hours, otherwise you will lose the right to the retouching and will pay the value of a MAINTENANCE
of:____________________. I declare that I am not included in the list of “risk clients”, nor do I have any infectious disease, I
do not have any symptoms of immunological weakness, I am not dependent on alcohol or drugs. And I confirm that the
statements above are true, assuming full responsibility for any omissions or errors thereof.

I declare that I am of legal age and that I am submitting myself to my own ______________________________ of
free will. I certify that all of the above items have been explained to me in detail and that no questions remain. I allow
the use of photos and videos of the technique for dissemination on social networks and articles.

Therefore, I sign this authorization.

in in .

Signature of the Client