Medical Form

Permanent Makeup Medical Form

Please fil out this form on or before your first appointment.  Your answers will better help us to meet your needs an ensure that you have a happy and satisfying experience

Mandatory for Florida Health Department
If none then write NONE

Please read carefully

Ombre Powder Brows is a way of cosmetic tattooing, intended to be semi-permanent lasting an average of 12-18 months.  On a rare occasion, the pigment may migrate under the skin.  The permant makeup proceedure may be uncomforable.  Although extremely rare, there might be an immediate or delayed allergic reaction to pigment.  A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure.  Allergic reactions to anesthetic can occur.  Permanent cosmetics cannot be performed if you are pregnant or nursing, or under the age of 18 years old.  Infections can occur if aftercare instructions are not followed correctly.  There may be swelling and redness following the procedure.  You may experience minor bleeding.  If you have an MRI scan within 3 months after the procedure, you should notify/discuss with your doctor. Scarring is possible.


Ombre Powder Brows procedure normally requires multiple treatment sessions. For best results, clients will be required ot return for at least one re-touch appointment. This will take place 6-10 weeks after the initial procedure. Those with oily skin may require anadditional touch up

• Please be aware that color intensity will be significantly darker and sharper immediately a few days after the initial procedure, but the color will reduce by 30-50%

• Although numbing cream is used during the procedure, sensitivity or discomfort may stil be felt. Skin may be red and/or swollen after the procedure.

• Please wear your normal make up on hte day fo your procedure • Please do not drink alcohol 24 hours prior to the treatment.

•Where possible, try to avoid the following herbs and spices prior to your appointment: Black pepper, Cardamom, any member of the Zingiberaceae (Ginger) family, Cayenne, Cinnamon, Garlic, Horseradish, Mustard.

• A patch test will be performed if requested by the client.  Patch test must be done 1 week prior to appointment date to allow for signs of sensitivity to appear.

•Please do not shape or wax your brows before the procedure. Your technician will shape brows during the procedure.

• No electrolysis for at least 5 days before the procedure.

Botox, AHA products and retinoids should be avoided for 2 weeks prior to the procedure.

• Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior ot procedure.

• Chemical and laser peels should be avoided no less than 6 weeks prior to procedure.

• Patients prone to cold sores/fever blisters should take an anti-viral prior ot treatment.

•Hormone therapies can affect pigmentation and/or cause sensitivity.

Topical Anesthetic Advice

Allergic reaction can occur from any anesthetics used during the procedure.  If you do suffer from an allergic reaction, you should contact your doctor imediately.  Allergic reaction response may show through redness, swelling, rash, blistering, dryness, or any other symptoms associated with an allergic reaction.


We cannot accept responsibility if the area to be treated does not respond to the numbing cream.  Each individual is different according to skin type.  Some clientsreport the area to be completely numb, while others may experience some discomfort.


For the ombre powder brow procedure, a numbing cream/gel is used.  The products are formulated to be perfectly safe and can e purchased over the counter from any pharmacy/chemist.  The anesthetic is placed over the treatment area for 3-5 minutes then carefully removed. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness/swelling that can last 1-4 days.  You should always follow your post procedure advice and after care for the best results.


• Liver disease (high risk of infection
• Pregnancy/Nursing
• Compromised skin near brow area
• Chemotherapy/Radiation
• Under 18 years old

The following medical conditions require a note from your doctor giving concent

•Diabetes Type 1 & Type 2
• High Blood Pressure
•Auto Immune Disease
• Thyroid/Graves Disease
• Any other condition that causes slow healing or a high risk infection

My printing your name you are electronically signing that you understand the above information and is 100% truth