Forms

Caring for your Micropigmentation Before & After Your Appointment

Even if you have had Micropigmentation done in the past, there is important information you will need to know both before and after your appointment. This will ensure that the appointment and the healing process both go as smoothly as possible. 

 

Before your micropigmentation appointment, please fill out, sign and bring each of the following forms with you to your appointment:

Client Consent 

Client Medical Profile

Pre-Procedure Instructions

Post Procedure Care & Healing Schedule

Southborough Consent Form

COVID-19 Liability Release

**We will not be able to perform the procedure, and your appointment will be cancelled, if you have one of the listed contraindications (see below), didn't follow all the before care, or will engage in an activity that will interfere with your aftercare & healing process. We reserve the right to refuse service to anyone who we deem not suitable for this procedure or for any other reason.

 

Contraindications

MEDICAL CONTRAINDICATIONS THAT PREVENT US FROM PROVIDING SERVICE

  • Allergy to topical makeup, dyes and/or numbing agents - (Gold, silver and nickel, lidocaine, prilocaine, benzocaine, tetracaine or epinephrine)

      **Please make us aware of any allergies upon booking.

  • Pregnant and/or Nursing

  • HIV/AIDS

  • Hepatitis B/C

  • Lupus

  • Diabetes Type 1

  • Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis (within 1” of the area to be treated), Eczema, Pink Eye, SunBurn, Severe Acne, Warts

  • Active Vitiligo

  • Blood Disorders: Sickle cell, Hemophilia

  • Keloid formation

  • Severe Rosacea

  • On Antibiotics

  • On blood thinning medication

RESTRICTIONS

  • Topical creams/Accutane or other strong retinoids (Must wait 6 months after treatment ends)

  • Retinol/Retin-A (Discontinued 7 days prior to procedure)

  •  Injections (Botox, Radiesse, JuvaDerm, Voluma, etc.) ( 2 weeks before or 2 weeks after the procedure)

  • After chemical peels (60 days before or after procedure)

  • Latisse (Discontinued at least 3 months prior to your eyeliner procedure)

 

MEDICAL CONTRAINDICATIONS THAT REQUIRE A DOCTOR'S NOTE

  • Diseases such as cancer, epilepsy, and autoimmune disorders 

  • Diabetes

  • Current or completed chemotherapy treatments (within the last 2 years)

  • Circulatory disorder

  • Bleeding disorders 

  • Artificial heart valves

  • Heart, blood, and/or liver disorders/diseases

 

Office (508) 299-6159 - Cell (774) 359-5896

155 Boston Rd  - Suite 11- Southborough, MA  01772

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