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LUXX Beauty & Brow Bar
Microblading & Permanent Makeup Consent Form

 

This form provides information about microblading, which is a permanent makeup technique.
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. Within a few weeks the color will fade 20-30%, soften, and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched up within 9-18 months. All instruments that enter the skin are disposable & are disposed of after each use. Cross contamination guidelines are carefully adhered to as well as universal precautions. 

Skin quality, skin care routine, UV and environmental exposure as well as abidance of aftercare instructions are all major factors in outcome of microblading and permanent makeup. certain skin types are not ideal candidates for microblading; Oily skin, large pores, mature skin, & frequent tanners may experience color migration in which the strokes make widen and blur as well as a color change in the deposited pigment. 

Our bodies contain natural foreign body fighting components, their job is to surround and break down foreign substances and implants in our body. They cannot easily break down and disperse large particles and tend to spread them out under the skin. This results in hazy & widely healed strokes. It is each individual's immune system response and is beyond your artist's control. Generally, the results of microblading are excellent. However, a perfect result immediately following initial procedure is not a realistic expectation & it is usual to expect a touch up after the healing is complete.

Please note: With microblading, the results are a very natural fuller looking brow. Initially, the brows appear darker but fade significantly over a two week period. It is normal to need a touchup. It is very difficult to predict how well your skin will retain pigment or how it will heal. Due to this and many other various factors, we cannot guarantee your individual results but will do our best to please each client. Individual results may vary. Refunds are not offered at any time, for any reason.

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.
UNEVEN PIGMENTATION: This can result from poor aftercare adherence, infection, excessive bleeding (taking aspirin, caffeine, alcohol) 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. Swelling during the procedure distorts  the natrual curves of our face. 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 2-5 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.


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

CONSENT FOR MICROBLADING & PMU PROCEDURE:
Please read and initial all lines

 

I am currently not under the influence of any drugs or alcohol.



 

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 cosmetic filler procedures within the past two weeks. 



 

I have not had any surgery of any kind or had antibiotics in the past 6 weeks. 



 

I have not taken any blood thinning medication within the past 72 hours nor have I taken Aspirin, caffeine or alcohol within the past 24 hours. 



 

********
AFTERCARE INSTRUCTIONS:
-2x A DAY: With clean hands, wash the area thoroughly with cleanser & warm water then pat dry
- 2x A DAY: Apply a THIN layer of aftercare cream provided (too much will delay healing)
- NO BROW MAKEUP FOR 7 DAYS!!! (Or anything but the above!! You have open wounds & we want to keep germs out!)
- No scratching or picking. Itchiness is normal as skin is healing. It’s important not to scratch or pick them as you will disturb 
the natural healing process & may pull out pigment. How you take care of your brows will have a great impact on the way they heal!
- Stay out of the sun! UVA exposure has been proven to cause a shift in color, excessive fading as well as pigment migration & blurred strokes. Always use sunglasses or hat.   SPF can be used on the brows after 7 days. 
- No standing water or ocean for 7 days! No baths/pools/ocean-these can harbor bacteria. And well…you have open wounds.
- NO RETINOL, LASERS, CHEMICAL PEELS, TANNING, GLYCOLIC, AHA near brows, ever! This will cause excessive fading
- The entire healing process will take from 4 - 6 weeks – a touchup can NOT be done prior to 4 weeks.
- Due to the skin regeneration process, after the recovery period the brows may appear lighter than original. Often, even with proper care, clients have fading and lose some strokes, which makes brows look uneven. This is absolutely NORMAL because your natural skin type & skin regeneration, this is not a process that the artist cannot control. That’s why around 60% of clients need a touch up, to assure that brows are perfectly even & the desired effect was achieved.
- Contact a physician if you experience signs of infection such as redness, warmth & swelling of pigmented area!
********

I have read the above aftercare instructions & I understand that they can also be found at www.luxxbbb.com 
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 read the aftercare sheet provided in my LUXX Aftercare Kit at my appointment, review the aftercare on the LUXX website, or contact LUXX 


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 and cause excessive fading. 



 

I understand that UV from the sun, tanning beds, pool chemicals, some skin care products and medications will affect the appearance of my permanent makeup. 



 

I accept the responsibility for explaining to my artist 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 (such as oily skin, dry skin, skin care products natural immune system, sleeping side, UV exposure) and I will need to maintain the color by protecting my brows from all things advised by artist and on my Aftercare Information Sheet and follow up with nearly touchups including a Perfecting Touchup 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, pigment migration and hyper-pigmentation.



I know the cost of today's appointment which does not include a 4-8 week perfecting touch-up following today's appointment. If you miss or choose not to come for a 4-8 week touchup, you will book need to book the next touchup depending on length of time since last session. 


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 my chosen artist at LUXX Beauty & Brow Bar LLC, to perform the microblading or PMU procedure on me.
I hereby release my chosen artist and LUXX Beauty & Brow Bar LLC and its affiliates from any liability arising from the risks that are known and/or inherent in the microblading procedure.

Today's Date: December 26, 2024

First Client’s Name

First Name*

Last Name*

Phone*
First Client’s Date of Birth*
First Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
First Client’s Signature*
Second Client’s Name

First Name*

Last Name*

Phone*
Second Client’s Date of Birth*
Second Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Third Client’s Name

First Name*

Last Name*

Phone*
Third Client’s Date of Birth*
Third Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Fourth Client’s Name

First Name*

Last Name*

Phone*
Fourth Client’s Date of Birth*
Fourth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Fifth Client’s Name

First Name*

Last Name*

Phone*
Fifth Client’s Date of Birth*
Fifth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Sixth Client’s Name

First Name*

Last Name*

Phone*
Sixth Client’s Date of Birth*
Sixth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Seventh Client’s Name

First Name*

Last Name*

Phone*
Seventh Client’s Date of Birth*
Seventh Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Eighth Client’s Name

First Name*

Last Name*

Phone*
Eighth Client’s Date of Birth*
Eighth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Ninth Client’s Name

First Name*

Last Name*

Phone*
Ninth Client’s Date of Birth*
Ninth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Tenth Client’s Name

First Name*

Last Name*

Phone*
Tenth Client’s Date of Birth*
Tenth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
No
Yes
Client’s 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 to receive information, news, and discounts by e-mail.
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
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar will take before and after photos depicting the results of your procedure for our records. Please choose "yes" or "no" below to indicate whether you also consent to our use of your photographs.*

Important notes/instructions for technician:

Do you have or previously had any of the following:

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.*

Age date of service?
**SECONDARY topical pre-numbing agents can be used at client's request to make the procedure more comfortable. **We do not use PRIMARY topical numbing before services. PRIMARY topical numbing agents can make the skin tough, rubbery, and make the application of microblading & permanent makeup more difficult for the artist to perform.They also cause more pigment migration which makes the strokes heal more hazy than expected. There is also a possibility that the color not heal as expected. We see MUCH better results when not using PRIMARY numbing agents prior to the procedure. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure? ***Please be advised that numbing agents may contain: Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine. If you have an allergy or sensitivity to any of these please and want to numb, please select "I HAVE AN ALLERGY TO A NUMBING INGREDIENT*** and we will discuss the appropriate numbing agent for you.*
Yes, I wish to receive topical during my service.
No, I do NOT wish to receive topical during my service. Apply numbing DURING procedure ONLY!
I HAVE AN ALLERGY TO A NUMBING INGREDIENT
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, Benzocaine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol,
 Vitamin E Acetate, etc*
No
Yes
Diabetes*
No
Yes
History of MRSA*
No
Yes
Hepatitis A B C D*
No
Yes
Easy Bleeding/Hemophilia*
No
Yes
Pregnant now - Microblading/Shading can NOT be done while pregnant.*
No
Yes
Exclusively breastfeeding now*
No
Yes
Supplementing breastmilk or Pump & Dump
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes

Please list conditions as this may effect the outcome of the procedure
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes, in the past 6 months.
Yes, last treatment was over 6 months ago

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes in the area you are receiving treatment? A course of prescription anti-viral medication is recommended before receiving treatment*
No
Yes - I am on a course of antivirals
Yes - I have not taken a course of antivirals immediately prior to this appointment
Infectious diseases now/high fever*
No
Yes

When
Epilepsy*
No
Yes
Do you have a pacemaker?*
No
Yes
Oily Skin*
No
Yes
Dry Skin*
No
Yes
Accutane or acne treatment*
No
Yes - last use was within 6 months of today
Yes - last use was over 6 months ago

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes

Date of procedure
Chemical Peel*
No
Yes

Last treatment
Brow Lash Tinting*
No
Yes

Last treatment
Tan by booth or salon*
No
Yes

Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?*
No
Yes
Did you have any surgery in the last 14 days?*
No
Yes
Allergies to metals, food, etc*
No
Yes

Allergies
Any diseases or disorders not listed*
No
Yes

Any diseases or disorders not listed
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?*
No
Yes

Please list any/all medications you are taking
I agree that all the above information is true and accurate to the best of my knowledge*
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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