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LUXX Beauty & Brow Bar
Microblading & Permanent Makeup Consent Form

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 10-20%, soften, and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched up within 6-18 months. All instruments that enter the skin or encounter body fluids are disposable & disposed of after each use. Cross contamination guidelines are carefully adhered to.

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. centail skin types are not ideal candidates for microblading; Oily skin, very dry skin, large pores, mature skin, & frequent tanners may possibly experience color migration in which the strokes make widen and blur as well as a color change in the 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 beyong LUXX, and the cleints, 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 imperative to have 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 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.

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

CONSENT FOR MICROBLADING 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 other cosmetic filler procedures within the past two weeks. 

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

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 (such as oily skin, dry skin, skin care productsnatural immune system, sleeping side, UV exporure) and I will need to maintain the color with future applications and a touch-up session in 4-6 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) perfecting touch-up within 4-6 weeks following today's appointment. After 8 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 Jessie Winn, owner of LUXX Beauty & Brow Bar, to perform the microblading procedure on me. I hereby release Jessie Winn, and LUXX Beauty & Brow Bar and its affiliates from any liability arising from the risks that are known and/or inherent in the microblading procedure.

Today's Date: February 21, 2020

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 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Second Client’s Date of Birth*
Second Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Third Client’s Date of Birth*
Third Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Fourth Client’s Date of Birth*
Fourth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Fifth Client’s Date of Birth*
Fifth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Sixth Client’s Date of Birth*
Sixth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Seventh Client’s Date of Birth*
Seventh Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Eighth Client’s Date of Birth*
Eighth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Ninth Client’s Date of Birth*
Ninth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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*
Tenth Client’s Date of Birth*
Tenth Client’s Information
OPTIONAL PHOTO RELEASE CONSENT: LUXX Beauty & Brow Bar 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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

Emergency Contact's 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.
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 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 choose "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.*

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?
Topical numbing agents can be used at client's request to make the procedure more comfortable. Please be advised that numbing agents may contain: Lidocaine, Prilocaine, and/or Epinephrine. These topical numbing agents can make the skin rubbery, making the application of microblading and permanent makeup more difficult. They can also cause the results to heal more blurry than expected. There is also a small possibility that the color not heal as expected. Acknowledging these possibilities, would you like a topical numbing agent applied prior to your procedure?*
Yes, I wish to recieve topical numbing.
No, I do NOT wish to receive topical numbing.
Difficult numbing with dental work*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Prilocaine, 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*
No
Yes
Breastfeeding now*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Abnormal Heart Condition*
No
Yes
Autoimmune disorder*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy/ Radiation*
No
Yes

Year
Tumors/ Growth/ Cysts*
No
Yes
Skin diseases*
No
Yes
Eczema*
No
Yes
Are you prone to herpes?*
No
Yes
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

Completed When?
Botox*
No
Yes

Last treatment
Forehead/Brow Lift/Facelift*
No
Yes
Chemical Peel*
No
Yes

Date of procedure

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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