Before your appointment

Consent — Brows

Please complete this form before your brow appointment. It takes a few minutes — your answers help us keep your treatment safe and tailored to you. The form is sent securely to Tabasom.

Prefer a PDF? Download the consent form (PDF), fill it in, and email it back to tabasomfashandi@gmail.com.

Your appointment requires a completed consent form. Please submit this form at least 24 hours before your appointment. If anything in your health has changed since you booked, please let us know.

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1. Client Medical History

Date *

Birthdate *

Age

Name *

First

Last

Form of ID #

Address

Phone *

Email *

Emergency Contact Person

Emergency Contact Phone

Medical History — check YES for any item that applies to you

History of MRSA
Botox (last treatment)
Diabetes
Hepatitis A / B / C / D
Forehead / Brow Lift
Easy Bleeding
Facelift
Alcoholism
Abnormal Heart Condition
Take medication before dental work
Chemical Peel (last treatment)
Pregnant now
Breastfeeding now
Brow / Lash Tinting
Autoimmune disorder
Oily Skin
Cancer (year)
Accutane or other acne treatment
Chemotherapy / Radiation
Tan by booth or salon
Tumours / Growths / Cysts
Difficulty numbing with dental work
Taking blood thinners (Aspirin, Ibuprofen, Alcohol, Coumadin, etc.)
Allergic reaction to medications (Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.)
Allergies to metals, food, etc.
Any diseases or disorders not listed
Use of skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl
Currently taking medication (list below)

Check every item that applies to you — leave an item unchecked for No. If an item needs more detail (for example allergies, medications, or a condition), please describe it in the next field.

Please specify — allergies, medications, conditions, or anything else from the list above

Your signature (type your full name) — I confirm the information given above is true and accurate *

Date of signature *

2. Consent and Release Agreement *

I have read the Consent and Release Agreement above and I agree to it.

I am choosing 3D Eyebrow / Microblading, a semi-permanent makeup procedure. I understand there is no guarantee of benefit. Pigment is implanted into the basal layer of the epidermis — this is a form of tattooing and, although it is considered semi-permanent, it is a permanent marking. All instruments used are disposable, and cross-contamination guidelines are followed. I understand a perfect result is not a realistic expectation, and a touch-up is expected after healing. Colour appears darker at first and fades 40–50% in 5–7 days. Pigment fades over time, and additional touch-ups are likely within 6 months to 2 years.

for Consent completed

3. Photography Release Consent *

Yes — you may use them
No — do not use them

Special requests, concerns, or remarks for the artist

4. Possible Risks, Hazards, or Complications *

I have read the risks above and consent to the procedure.

Possible risks, hazards, or complications include: Pain; Infection; Uneven Pigmentation; Asymmetry; Excessive Swelling or Bruising (1–5 days); Anesthetics — the anesthetics used may contain Lidocaine, Prilocaine, Benzocaine, Tetracaine, and Epinephrine — please tell us about any allergy to these; MRI — pigments contain inert oxides, so please inform your MRI technician; Allergic Reaction. The alternative to this procedure is to use traditional cosmetics and NOT undergo the procedure.

5. Procedure Record — to be completed by the artist

Pigment Brand / Catalog

Colour(s) / Formula

Batch No(s)

6. Statement of Consent & Recitals — Please read and check every line.

Statement of Consent & Recitals *

Aftercare instructions have been explained to me and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email you.
I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.
I understand that although the European technique performed correctly is considered semi-permanent since it fades and exfoliates out with the skin over time, strokes and markings are considered permanent by nature and by the Health Department.
I understand that Retin-A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the colour and cause premature exfoliation of the pigment.
I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup.
I understand that successful colour saturation can NOT be guaranteed due to hidden scar tissue.
I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.
I accept the responsibility to explain to you my desire for specific colours, shape, and position for any procedure done today.
I understand that implanted pigment colour can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the colour with future applications and a touch-up session within 60 days.
I acknowledge that the proposed procedure(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedure such as: infection, misplaced pigment, poor colour retention, hyper-pigmentation, scarring, bleeding, & nerve damage.
I have been advised that a touch-up session is highly recommended to make any adjustments to shape, colour, and to fill any pigment that may have had poor retention. Touch-ups must be completed within 60 days of the initial procedure.
I have been quoted the cost of today's appointment, and the cost of the touch-up. Touch-ups must be completed within 60 days of the initial procedure to be considered a touch-up price.

Certification & Signature *

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. 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 Tabasom Fashandi as my Eyebrow Microblading technician to perform on my body the 3D Eyebrow Microstroking procedure desired today.

Full name (signature) *

Date *

Stay in touch (optional)

Yes, I would like to receive birthday wishes, holiday specials and offers from Tabasom Fashandi by email or text message. (Optional)

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