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1914 Charlotte Ave, #102
Nashville, TN 37203

 

WAIVER CONSENT FORMS

 

Microblading Pre Care Instructions

Thank you for choosing LOVE BROWS for your Microblading experience.

Please make sure you read the following instructions to assure the best results for your procedure.

It is very important to refrain from all alcohol, aspirin, or aspirin products, such as blood thinners.

Please refrain from Ibuprofen and Aleve for 24 hours prior to your appointment.

The only product for aches and pain that will not make you bleed is Tylenol.

Also refrain from Vitamin E and fish oil capsules for 7 days prior to your application.

ALL of these make you bleed excessively. Excessive bleeding during the procedure will negatively affect the longevity of your semi-permanent makeup application. In some cases, the application will need to be prematurely stopped.

Please avoid energy drinks & coffee for up to 24 hours prior to your appointment. Not having caffeine in your system will help you to relax much more easily, as well as help to relax the facial muscles in the areas we will be working on. 

Please also read Contraindications, Preparation, Aftercare and Healing Process under F.A.Q on Love Brows website for more in depth details.

Thank you again and we look forward to seeing you.  You're one step away from having beautiful brows!!!

Consent to Application of Semi-Permanent Makeup Procedure

I am over the age of 18, I am not under the influence of drugs or alcohol. I am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.

PROCEDURE:  MIRCOBLADING
NO. OF VISITS REQUIRED: 2   
COST OF PROCEDURE: $350.00 - $400.00

I have been informed of the nature, risks, and possible complications or consequences of semi-permanent pigmentation. I understand the semi-permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of procedure, including but not limited to the following: infections, scarring, inconsistent color, and spreading, fanning or fading of pigments.

I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this a form of tattooing and therefore not an exact science, but an art. I request the semi-permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of Mircoblading.

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.

I have received both pre and post care procedural instructions and I will strictly adhere to such instructions. I understand that my failure to do so many jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly adhere to my doctor’s instructions before contemplating any semi-permanent cosmetic procedure around the lips.

I understand that taking before and after photographs of the said procedure are a condition of the procedure. I certify that I have read and initialed the above paragraphs and have had explained to me this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.  

Microblading  Cancellation Policy

Please read our cancellation policy as a courtesy to LOVE BROWS professionals, and in order to efficiently accommodate other clients.

The initial deposit of $50.00, is non-refundable.

If you need to reschedule your appointment, a  48 hours notices is required. Failure to notify our studio will result in a $50.00 fee.

If a medical emergency arises, you must provide the proper medical documentation.

By signing this agreement, you acknowledge that you have read, understood and agree to all terms above.

Thank you and we look forward to assisting you.

 Post Procedural Care for Eyebrows

DAY 1:

  • Please wash hands with antibacterial soap before you attempt to clean your eyebrows. Then use cotton ball to gently wipe your eyebrows every 1-2 hours. Do this 2-4 times today to avoid any build-up of blood/lymph on the area.
  • Pat dry with a tissue than apply a very thin layer of the Skin Candy. This is just to add a small amount of moisture-brows should not appear greasy, glossy or shiny, if they do, you used too much.
  • Do not use aggressive movement/manipulation of the skin-be gentle.

DAY 2-7:

  • Keep eyebrows lightly glossed with the Skin Candy for three to four times a day for the next 7 days. Do not over use ointment. It should last you for 7 days, only apply very thin layer. Do not suffocate your eyebrows.
  • Do not use any Retin-A, Glycolic Acids, Peroxide, Neosporin while healing
  • Do not scrub or pick your eyebrows.
  • Do not expose area to sun or tanning beds! Must use hat if in the sun.
  • Avoid any facials ,swimming, whirlpools or sauna for 7 days.
  • Do not exercise the first 3-5 days. No heavy sweating !
  • No make-up on the eyebrows!
  • Do not tint eyebrows for the next 20 days.

FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN LOSS OF PIGMENTS.

Please also read Contraindications, Preparation, Aftercare and Healing Process under F.A.Q on Love Brows website for more in depth details.

WHAT TO EXPECT AFTER MICROBLADING OR EYEBROW SHADING PROCEDURES:

Slight swelling, thickness, and/or redness for one or two days following the procedure.

It is normal to lose approximately 1/3 of the color during the healing process.

After the initial procedure, the color may be a shade too dark; in six days it will appear to light after 10 days the color will show more.

It will appear softer when completely healed because the color will come from dermal layer of the skin to the epidermal layer of the skin.

Please be patient. Healing takes up to 30 days. In your next appointment more hairs can be added and make them perfect.

The brows are approximately 20 to 25% darker and bolder in the width than they will be when healed. Your skin is red under the pigment which causes the color of the pigment to appear darker. There is some swelling, although difficult to actually see due to the thickness of the skin in the eyebrow area. This will subside. Exfoliation, which begins in a few days, will cause the excess pigment surrounding the eyebrow procedure to flake away and a narrower appearance of your eyebrows. Don’t be concerned that your eyebrows initially appear darker and heavier in size then you desire. This is all part of the process.

Please also read Contraindications, Preparation, Aftercare and Healing Process under F.A.Q on Love Brows website for more in depth details.

By signing this agreement, you comply with these terms.
Please do not hesitate to contact us if you have any questions about the post procedural care.

Today's Date: November 22, 2019

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
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*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Patch Test

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. It's highly recommended if you have allergies if not, we find it's historically rare to have an allergic reactions with pigments. You will need to schedule a separate appointment for patch test if you requested one.*

Confidential Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions


Do you have previous Permanent Make Up?*
No
Yes

If yes, when?
Are you over the age of 18?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so, when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
re you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain:
Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all:

Doctor's Name and Number:
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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