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House of Wax Microblading

 

 

House of Wax Microblading Consent Form
​2216 Dundee Rd Suite 1, Louisville KY 40205
Salon registration #_____


This form provides information about microblading, which involves the application of semi-permanent makeup. You are encouraged to carefully review the information provided to make an informed decision as to whether to undergo the microblading procedure. Microblading involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing. Initially the color will appear 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 12-18 months. All instruments that enter the skin or encounter body fluids are disposable and disposed of after each use. Cross contamination guidelines are carefully adhered to. Generally, the results of microblading are excellent. However, a perfect result is not a realistic expectation, it is usual to expect a touch up after the healing is complete.

READ BELOW:
IF YOU ARE PREGNANT OR BREAST FEEDING YOU MAY NOT RECEIVE THIS SERVICE. IF YOU HAVE ANY HISTORY OF KELOIDS YOU MAY NOT RECEIVE THIS SERVICE.
IF YOU PLAN ON USING A TANNING BED AGAIN YOU DO NOT WANT TO RECEIVE THIS SERVICE BECAUSE THE TANNING BED 100% WILL ALTER YOUR RESULTS,
NO AMOUNT OF SPF OR COVERING YOUR FACE WILL EVER PREVENT THIS, IT IS INEVITABLE. 
IF YOU HAVE LUPUS OR HAVE AN AUTOIMMUNE DISEASE - YOU MUST HAVE A DOCTOR'S NOTE TO BOOK THIS SESSION. YOU MUST HAVE MEDICAL CLEARANCE.


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 unevenness. 
EXCESSIVE SWELLING OR BRUISING: Some people bruise and swell more than others. Ice packs may help, and the bruising and swelling typically disappear within 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.    
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.

PLEASE INITIAL to WAIVE patch test 



The alternative to these possibilities is to use cosmetics and not undergo the microblading procedure. 

CONSENT FOR MICROBLADING PROCEDURE: 
Please read and initial if all following statements are true:

  • I am currently not under the influence of any drugs or alcohol.
  • I have not been out of the country within the last 14 days.
  • I have not experienced any symptoms or ailments for 14 days.
  • I have not been around anyone diagnosed with COVID19 for the past 30 days.
  • I am NOT pregnant.
  • ​I do not currently take nor have taken Accutane within the last 12 MONTHS.
  • I have not had Botox and/or other cosmetic filler procedures within the past two weeks.
  • I have not had any surgery of any kind in the past 6 months.
  • I have not taken any blood thinning medication within the past 72 hours nor have i taken Aspirin within the past 24 hours.
  • Aftercare instructions have been explained to me and are attached to this consent form. A written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If i have questions I will contact my technician.
  • I will contact my physician if I notice any infection beginning to form.
  • I understand a certain amount of discomfort is associated with this procedure and that swelling, redness, and bruising may occur.
  • I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color.
  • I understand that the sun, tanning beds, pools, some skin care products and medications may affect my permanent makeup.
  • I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done today.
  • I understand that implanted pigment may changer or fade over time due to circumstances beyond the salon's control and I will need to maintain the color with future applications and a touch-up session in 4-8 weeks.
  • I acknowledge that the microblading procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedure such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
  • I have been quoted the cost of today's appointment which includes (1) touch-up within 4-8 weeks following today's appointment. After 12 weeks, a fee will apply for any further touch-ups. There will be no refund for this elective procedure.
  • I acknowledge that I am at least 18 years of age and 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 materials given to me and I authorize Najla Keserovic, owner of House of Wax, to perform the microblading procedure on me. I hereby release Najla Keserovic, and House of Wax salon and its affiliates from any liability arising from the risks that are known and/or inherent in the microblading procedure.
    ​
    I Agree
    - Must agree to move forward with treatment

 

 

Signature:

 
Optional Photo Release Consent
House of Wax would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc. Please circle "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.
YES, feel free to use photos of me
​
I Agree


 
 

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Second Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Third Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


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Additional commentary/ concerns


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Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check box to receive updates on promotions and specials via email - House of Wax doesn't share clients emails with anyone. All information stays hidden.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
History of MRSA*
No
Yes
Easy bleeding/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding now?*
No
Yes
Cancer*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemotherapy / Radiation*
No
Yes
Tumors/Growths/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to Herpes*
No
Yes
Infectious diseases now/ fever now*
No
Yes
Epilepsy*
No
Yes
Do you have a pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox*
No
Yes
Forehead/ Browlift/ Facelift*
No
Yes
Tan by booth or sun*
No
Yes
Chemical peel*
No
Yes
Have you consumed drugs or alcohol in the last 48 hrs?*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Neosporin, Vitamin E Acetate etc.*
No
Yes
Did you undergo any surgery in the last 14 days?*
No
Yes
Problems with healing of wounds*
No
Yes
Allergies to metals or foods*
No
Yes
Any diseases or disorders not listed?*
No
Yes
Do you use skin care products containing Retin-A, Glycoloc Acids, Alpha-Hydroxy Acids?*
No
Yes
Do you exfoliate your skin weekly?*
No
Yes
Do you give consent for your photos to be used on social media? No face photos, strictly brows, just as a before & after photo.*
No
Yes

Please list any medications you are currently taking


Click to customize text box label

Additional commentary/ concerns


Click to customize text box label
Do you FULLY understand that any dissatisfaction/concern must come DIRECTLY to your artist & House of Wax LLC nor ANY of it's artists are to be slandered on ANY public forum whatsoever, for any reason at all, or legal action will be taken. House of Wax is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or ANY service done at your own risk & reward.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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