Shop2, 380 Logan Road. Stones Corner. Qld 4120 P:07 3397 6111. E:

Client Medical History

Do you presently have or previously had any of the following: (Circle yes or no)

This is a true and accurate statement of my medical history, past and present. I am aware that failure to disclose information pertinent to my treatment could have serious health ramifications. I am also aware that failure to disclose information pertinent to my treatment could have a direct bearing on treatment outcome.

This form is designed to give information needed to make an informed choice of whether or not to
undergo a Semi-permanent make up application. If you have questions, please don‘t hesitate to ask.

Although cosmetic semi permanent make up is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure. This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are stickily adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.

Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years.

Possible risks, hazards or complications

Pain: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.

Infection: Although rare, there is a risk of Infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care” sheet for instructions 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 symmetrical. adjustments may be needed during the follow up session to correct any unevenness. 100% symmetry is not possible.

Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-5 days. Some people don’t bruise or swell at all.

Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.

MRI: Because pigments used in permanent cosmetic procedures contain iron oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.

Allergic Reaction: There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7 day patch test to determine this.

The alternative to these possibilities is to use cosmetics and not undergo the cosmetic semi-permanent make up/ 3D Eyebrow Embroidery (Microblading) procedure.

Consent and release for procedures performed:


Please read and initial all lines

Photo Consent

Please note that we take photographs before and after every procedure for monitoring response to therapy

give my consent to Brow Mantra to use my photos for client records/social media/website/marketing purposes




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