Microblading Client Assessment Form

Personal Information

First Name

Last Name

Phone Number

Date of Birth

Emergency Contact Name

Emergency Phone Number

Medical History

Please tick Yes or No.

Do you have any allergies (including latex, pigments, or topical anaesthetics)?

Yes

Have you had chemotherapy or radiation therapy in the past 12 months?

Yes

Do you have any autoimmune conditions?

Yes

Have you had any recent illness or infection?

Yes

Do you have a history of keloid or hypertrophic scarring?

Yes

Do you have any skin conditions near the eyebrow area (eczema, psoriasis, dermatitis, acne)?

Yes

Have you used Accutane (isotretinoin) in the past 12 months?

Yes

If you answered "Yes" to any of the above, please provide details:

Brow History

Have you had microblading, cosmetic tattooing, or brow tattooing before?

Yes

Have you recently had Botox or dermal fillers?

Yes

Have you had a chemical peel, laser treatment, or skin resurfacing in the last 4 weeks?

Yes

Lifestyle

Have you consumed alcohol in the past 24 hours?

Yes

Have you taken aspirin or anti-inflammatory medication in the last 24–48 hours?

Yes

Have you had excessive sun exposure or used a tanning bed in the last 2 weeks?

Yes

Expectations

What is your desired brow style? (Natural, Soft, Defined, Bold, Other)

Do you have any concerns or specific goals for your brows?

I confirm that the information I have provided is true and complete. I understand that withholding medical information may affect my treatment. I have had the opportunity to ask questions and understand the procedure, risks, aftercare, and healing process.

Client Signature:

Date:

Therapist Signature:

Date: