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C O N T R A I N D I C A T I O N S 

In medicine, a contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment due to the harm that it would cause the patient.Contraindication is the opposite of indication, which is a reason to use a certain treatment.

Please read through this document thoroughly. 

This information is used to determine if you are a good candidate for the procedure.

Unfortunately, not all clients are good candidates for microblading due to their compromised skin condition or pre-existing medical conditions.  

Please inform us if any of the  contraindications below apply to you prior to booking your appointment. 

A doctor’s clearance may be necessary for certain health conditions. Failure to make us aware of the contraindcations that apply will result in a forfeit of the procedure and any payments made for the appointment. 

 

The following medical conditions require a note from your doctor giving consent:

  • Uncontrolled Diabetes Type 1 and 2 and Diabetics who are on insulin
  • Uncontrolled high blood pressure
  • Auto-immune disease
  • Thyroid / Graves’ disease
  • Any other medical condition that causes slow healing or a high risk of infection
  • People with glaucoma (for eyeliner clients only)
  • Those with easily triggered post inflammatory hyper-pigmentation
  • Those undergoing radiotherapy or chemotherapy treatment at present (or due to undergo such treatment) and any radiotherapy or chemotherapy that came to an end less than 42 days ago from the date of the treatment
  • Those on skin medications such as roaccutaine, antasure, steroids
  • Epileptic that has experienced a seizure in the last two years

We absolutely CANNOT perform the procedure on those who encounter the following contraindications:

  • Those under the age of 18 (even with parental consent)
  • Those with transmittable blood conditions like HIV or Hepatitis
  • Pregnant / Lactating women
  • Active skin cancer in the procedure area

Other  contraindications to be made aware of: 

  • Not following the before care instructions or being able to follow the aftercare instructions. (This applies to every scheduled appointment, not just the original procedure)
  • Flu or cold: Please reschedule your appointment if you have a cold or flu
  • Consuming alcohol or caffeine the day before and of the procedure. Doing so will increase blood flow/thinning causing you to bleed which pushes the pigment out and results in less color retention
  • Working out the day before or the day of the procedure
  • If you are or took antibiotics less than 3 weeks from your procedure date
  • People allergic to nickel (must inform us at the time of booking so we can use a different blade for you)
  • People who are taking blood thinning medicines (have to stop using prior to the procedure, please consult with your doctor)
  • People with active acne right on the eyebrows can still have the procedure but will need to avoid the acne area. The same will be done with skin tags and molds
  • People with allergies to makeup or pigmented colors
  • If you’re a blood donor, you may not give blood for 1 year following your procedure (Per Red Cross)
  • If you are a hemophiliac
  • People prone to keloids
  • People who are anemic

If you’re unsure if microblading is for you or are concerned about the possible implication, a “patch test” can be performed. Once client agrees to have the patch test performed, Huemon Beauty will make a small sample in the skin behind the clients ear and will then send them home to follow up with their physician within 5- 7 days. This test is taken to ensure that the client does not have any allergic reactions or health concerns to the applied pigment.

If the client wishes to take the patch test, they must waive this option at the bottom of this document. By electing to take this test  the client will not be able to have any microblading procedures performed untill they have recieved a written consent from their document and provided it back to Huemon Beauty, LLC. 

 

W E E K S   B E F O R E    Y O U R   P R O C E D U R E 

  • Please, plan your vacations accordingly to your appointments. It will take about 4-5 weeks for your eyebrows to fully heal after initial procedure, and touch-ups. Rays can alter the pigment. Please no intentional tanning 4 weeks prior to application. If you get sunburn on your face, you must allow it to heal for 4 weeks.
  • You must stop taking antibiotics 3 weeks from your procedure. Please consult your doctor before doing so.
  • No laser procedure or peels should be done 4 weeks prior to your microblading procedure.
  • No intentional tanning 4 weeks prior to application. If you get sunburn on your face, you must allow at least 4 weeks for it to heal.
  • If you don’t feel well in general, have a cold or any symptoms of sickness, please contact us to reschedule your appointment.
  • No waxing, tweezing or tinting 3 days before the procedure; electrolysis no less than 5 days before. Do not resume any method of hair removal for at least 2 weeks.
  • Eyelash or eyebrow tinting and/or curing should be done no sooner than 48 hours before, or at least two weeks after the procedure.
  • Botox should be performed no sooner than at least 2 weeks prior to your appointment
  • Microneedling should be done no sooner than 2 weeks prior to your procedure.
  • Botox, AHA products and retinoid should be avoided for 2 weeks prior to the procedure
  • Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure

D A Y S    B E F O R E    Y O U R   P R O C E D U R E 

  • We suggest washing your hair before your appointment. You will not be able to get your eyebrows wet for at least 2 weeks.
  • 24 hours prior to your appointment, do not consume alcohol, caffeine or anti-anxiety/depression medications. Doing so will increase blood thinning, and can cause you to bleed and push out pigment – resulting in less color retention.
  • Do not take Asprin, Ibuprofen, niacin, vitamin E, Fish oil or any blood thinning medication.
  • Please note that you will be more sensitive to the microblading procedure during your menstrual cycle.


D U R I N G   T H E   P R O C E D U R E

Possible risks + hazards and/or complication

On average,  your initial microblading appointment may take between 3-4 hours. However, please note that we CANNOT guarantee this will be the time for all of our clients. It’s important that you understand that satisfactory results of this procedure depend 50% on the artist, and 50% is up to your skin and how you care for your tattoo after you leave our studio.

•• Allergic reaction – Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.

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

For microblading procedure, a numbing cream/gel is used. The products are formulated to be perfectly safe and can be purchased over the counter from any pharmacy/chemist (Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine cream or gel form typically used). The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness/swelling that can last 1-4 days. You should always follow your post procedure advice and after care for the best results.

**Uneven pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearances.

**Asymmetry: Every efforts will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness

 

Signs, Symptoms and Possible Infections

Although it's important to note that infections during the microblading process are VERY RARE (about 1-3% or 1-3 in 100 people), it's important to understand what risks it can include and how to treat it if your suspect it. 

It is highly crucial that you follow the aftercare process to a T as there can be a small risk (around 1-3%) that you may experience an infection if not taken with proper care. In mild cases, infections can be treated with over the counter antibiotics that can be topically placed on your skin. In extream, serious cases, you may need to see a doctor and recieve a perscibed antibotic that you cannont recieve over the counter. The biggest risk in developing a deep infection to the skin can turn into a condition known as "Cellulitis". Cellulities is an infection of the inner layer of the skin that can spread if not treated appropriately. Other conditons such as Nickel reactions and rashes can occur if the client is allergic to the pigment that is placed on their skin. (Please note, Huemon Beauty Pigments are water based and do not include Nickel but this is important to know in case you ever decide to recieve microblading services from another establishment.)  If you suspect that you have an infection, please contact a Huemon Beauty speciliast immediately

Early stage infection systems:

  • Odor comming from your eyebrow
  • Discharge that may be a greenish/brown color
  • Resness around the procedure area but not extending beyond it
  • Tenderness when touch *Please avoide touching your eyebrows after the procedure!

​Most of these systems can be treated as long as you catch it early. Please consider these tips if you have an early infection:

  • Consider using an antibiotic ointment like Bacitracin. Bacitracin will treat the most common skin pathogens such as staph and strep (even MRSA) and does not include ointments that can irritate the skin.
  • Avoid using triple antibiotic ointment like neosporin which contains neomycin that approximately 1 in 10 people react to with a rash (that's a LOT of people). 
  • Avoid covering up the microbladed brow with creams and gels such as vaseline or other emollients which can trap in heat and keep an infection in the wound (remember bacteria dies in the presence of oxygen)
  • Consider using a cold pack on your eyebrows to reduce swelling and heat, this can also help alleviate some of the pain/tenderness
  • Keep the area clean! Avoid using makeup or other topical agents (besides the antibiotic) on your skin/wound

​If the infection continues to develop and you begin to experience; exteme swelling/tenderness/pain or fever/chills (signs suggest you have a systemic infection) please contact your doctor ASAP. These are early signs that you may be developing facial cellulities and may need oral or IV antibotics.

 

General Reminders to Note During The Healing Process

After care is a crucial element to follow to ensure proper healing and color retention. Results vary for all individuals and we cannot guarantee your results.

Please do not use other products or follow other artist’s aftercare instructions during your healing process.

 

Any procedure that breaks the skin requires healing time, which can cause the healing process to be full of ups and downs. Here are some important reminders about the healing process to note during your journey.

  1. Always wash your hands thoroughly with anti-bacterial soap before touching the tattooed area. You don’t want to get the area infected!
  2. Do not wash your eyebrow area with soap.
  3. Never apply lotion/oil on damp or wet tattoo. Other oily products to avoid; Aloevera, vitamin E, Homeopathic/natural products. They can pull the pigment color out of your skin and cause healed results to look blurred or faded.
  4. Do not rub/scratch or traumatize the procedure area while it is healing; touching the procedure area with your fingers may cause an infection from unseen bacteria. Furthermore, your fingers may have added oils that can cause the pigment color to be removed.
  5. Sabbing in a normal part of the healing process. Don't freak out if your scabbing comes off and it looks like it's taking pigment away with it. This process can leave a "patchy" apperance to the brows which is why you should not pick at your scabs - let them fall off NATURALLY. Picking your scabs can cause scarring, premature loss of pigment/hair and even an infection. The approximate scabbing period is 14 days however, healing can be prolonged if you’re immune system is compromised if you are generally stressed, and by poor diet.
  6. No makeup around your eyebrows, lash tinting during the entire healing process – makeup with suffocate the area and won’t allow the area to breathe and heal properly -causing irritation and excessive scabbing
  7. No sweating (salt is your worse enemy and will draw out the pigment!); No heavy work outs, saunas, laying out in the sun, swimming in chlorinated pools/ jacuzzi’s/ocean until area is completely healed.
  8. If you have bangs or like to wear your hair on your face, you must clip them back for the first 7 days to avoid irritation and infection.
  9. Absolutely no sun exposure or tanning for 3-4 weeks after procedure.
  10. If you are a “face-sleeper” then sleeping on clean, satin pillowcase is suggest while the procedure area is healing.
  11. If you’re a blood donor, you may not give blood for 1 year following your procedure (Per Red Cross)
  12. Trust the process!

 

Statement of Consent and Recitals

Please read thoroughly and initial all lines

I am over the age of 18, am not under the influence of drugs or alcohol, I am not pregnant or nursing and desire to receive the indicated semi-permanent pigmentation procedure. The general nature of cosmetic micro-pigmentation, as well as the specific procedure performed has been explained to me. Furthermore I consent to the following:

To my knowledge, I DO NOT have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time.

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. Understanding that permanent skin pigmentation procedure carries known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments.

I authorize my technician to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances that any unforeseen conditions arise during the course of my procedure. 

I fully understand this is a tattoo process and therefore not an exact science but an art.

I accept the responsibility for determining the color, shape and position of the micro blading procedure as agreed during consultation.

I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin.

I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years. Even once the color fades, pigment itself may stay in the skin indefinitely. 

I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit. 

I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeated procedure.

Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed.

I have been advised that the true color will be seen 6 weeks after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. 

Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow the best of my ability. If I have questions, I will call or email you. 

I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.

I understand that Retin A. Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color .

Retin- A: Originally used as an acne treatement but now has numerous uses, including an exfoliating agent and “Keratolytic” (a product that removed a plug out of a hair follicle or sweat gland)

Alpha hydroxy acids (AHAs): is the group name for several types of acids that are naturally found in different foods and plants. They're a group of "peeling" agents that exfoliate chemically. They help prevent dead skin cells from sticking together, making it easier to exfoliate and giving you a more radiant, glowing skin.

Glycolic acid is part of the group of active compounds known as AHA's (alpha hydroxy acids). Derived from cane sugar: It has the smallest molecules in the group so is able to penetrate skin deeply and easily, making it the most effective for treating fine lines, acne, blackheads, dullness, oiliness etc.

I understand that sun, tanning beds, pools and some skin care products and medications can affect my permanent makeup. 

I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m scheduled for an MRI.

I accept the responsibility for my explanation to you of my desire for specific colors, shape and position for any procedure done today. 

I understand that implanted pigment color can slightly change or fade overtime due to circumstances beyond your control and I may need to maintain the color with future applications and touch up sessions within three (3) months of my initial procedure. 

I acknowledge that the proposed procedure(s) involve risk inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyperpigmentation. 

I have been quoted the cost of today’s appointment, which includes one (1) touchup within a two month (2) period and requires a $50.00 non-refunable deposit made to Huemon Beauty today. The remainig payment of the service(s) I've been quoted for today will be due at the time of service. I understand that Huemon Beauty does not provide refunds for this/these elective procedures if I cancel my appointment less than 72 hours of my appointment date. 

I understand that if I choose to reschedule my appointment, that the time I desire may not be avliable. If I need to reschedule my appointment and it exceeds  the two month (2 month) timeframe, I understand that I will be charged an additonal $100.00 for my intiial service/touch up service.

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(s) and I have had the opportunity to ask questions and all my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Deyonne Hallberg, owner and certified microblading technician/artist of Huemon Beauty, to perform on my body the Huemon Beauty microblading procedure desired today.

 

 

Release Agreement

Please read thoroughly and sign

This form is designed to give information needed to make an informed choice of whether or not to undergo Huemon Beauty’s Microblading Semi Permanent Makeup application. If you have questions, please don’t hesitate to ask.

Although Huemon Beauty is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing.

All instruments that enter the skin or come in contact with body fluids are disposable and disposed after use. Cross contamination guidelines VIA Govt. issued/training from Blood Borne Pathogen Protection are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. Initially the color will appear much more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time. Follow up appointments must be made within 4-6 weeks for best results and then generally touched up a 2nd time within 6 to 18 months. Please note the color may fade faster on oily skin.

 

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
First Client Signature*
Second Client Name

First Name*

Last Name*

Phone*
Second Client Date of Birth*
Second Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Third Client Name

First Name*

Last Name*

Phone*
Third Client Date of Birth*
Third Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Fourth Client Name

First Name*

Last Name*

Phone*
Fourth Client Date of Birth*
Fourth Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Fifth Client Name

First Name*

Last Name*

Phone*
Fifth Client Date of Birth*
Fifth Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Sixth Client Name

First Name*

Last Name*

Phone*
Sixth Client Date of Birth*
Sixth Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Seventh Client Name

First Name*

Last Name*

Phone*
Seventh Client Date of Birth*
Seventh Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Eighth Client Name

First Name*

Last Name*

Phone*
Eighth Client Date of Birth*
Eighth Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Ninth Client Name

First Name*

Last Name*

Phone*
Ninth Client Date of Birth*
Ninth Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Tenth Client Name

First Name*

Last Name*

Phone*
Tenth Client Date of Birth*
Tenth Client Information

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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

Today's Date

Referral Code


Please enter your referral code here to receive your discount

Client Address *

Client Email Address *

Statement of Consent

Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. You may take a 5-7 day patch test to determine this.*
We would like your permission to use these photos for advertising; i.e. professional portfolios, online marketing, print ads etc. Please indicate if you will authorize this usage*

Client History 

Please complete the following medical history inventory

Do you currently have or have ever had any of the following health concerns in your health history? PLEASE SELECT ALL THAT APPLY *
Abnormal heart condition
Cancer in the eyebrow area
Cancer/Chemotherapy/Radiation
Cholesterol and High Blood Pressure
Controlled Diabetes (*Please be sure to note if you are taking insulin or any other medications below)
Uncontrolled Diabetes
Hepatitis (A, B, C, D)
Thyroids
Tumors/growths/cysts
History of MRSA
N/A

If you answered yes to any of the above health concerns, please be sure to give us detail on when this health event occurred in your life, the medications you are currently taking as a result and any other pertain-ant information we need to know. If none of those options apply to you, please list "N/A" *
Are you currently pregnant/breast feeding?*
No
Yes
Have you had any of the following procedures done within the last 60 -90 days? *
Botox
Chemical Peal
Face Lift
Lip Fillers/Restylane/Juvederm
N/A
Are you prone to any of the following? *
Cold Sores/Fever Blisters
Easy Bleeding?
Keloids
N/A
Have you had any of the following work done in the "Brow" area? Check all that apply. *
Eyebrow Tattoo (Not the same as microblading)
Eyebrow Tinting
Eyebrow Threading
Eyebrow Lift/Forehead Lift
Microblading (Please indicate when your last service was and where you received it below)
N/A

If yes to any of the above, please indicate when you initially/last had these services performed. If no, please write "N/A" *Please note, all clients with previous tattoos MUST be evaluated prior to having a microblading procedure performed. *
Do you currently have any of the following skin conditions? (**Note: eyebrow-injured skin cannot be tattooed)
Eczema, Psoriasis, Dermatitis and Rosacea **(Note: All are constant flaking, itching, irritation and shedding of skin.)
Shingles
Ingrown hairs and open bumps on eyebrow
N/A
Do you currently take any of the following medications or skin care products? *
Accutane, Retin-A or products for acne treatment? (*Note must be off of accutane for 1 year & Retin-A must be off 30 days prior to procedure date)
Blood thinners such as: aspirin, ibuprofen, alcohol etc.
Do you use any skincare products containing retinol, alpha hydroxly Acid or Vitamin A? (**Note: Skin composition is altered and will not heal well. Must discontinue use 1 month prior to procedure.**)
N/A
Do you experience any reactions with the following?
Allergic reactions to any medications such as lidocaine, tetracaine, epipephrine, decracine, benzyl, carbopol, lecithin
Difficulty numbing with dental work/ take medication for dental work
N/A

Please list any medications or vitamins you're presently taking
Please note if you are taking any of the blood thinning medications (**Note: These medications will cause excessive bleeding, making it extremely difficult for your skin to retain the pigment**)*
Accutane (must be off medication for a year)
Cilostazol (Pletal)
Clopidogrel (Plavix)
Coumadin
Dipyridamole (Persantine)
N/A
Prasugrel (Effient)
Retin-A (must be off 30 days prior to procedure date)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)
Triflusal (Disgren)
Vorapaxar (Zontivity)
Warfarin

Special requests, concerns or remarks for the technician:
Please answer the following questions for EYELINER services ONLY
Eye surgery/ Injury/Corneal Abrasion
Wear contacts (now)
N/A
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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