Loading...

MICROPIGMENTATION

CLIENT CONSENT FORM

I am over the age of 18 and desire Brandell Hecker R.N to perform the elective cosmetic pigmentation procedure understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure(s).


I also understand that the cosmetic pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. Laser treatments may also compromise the cosmetic pigmentation procedure application. I fully understand as with all such procedures that this is not a science but rather an art and that anything that can go wrong may go wrong. I request the cosmetic pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s).


For the purpose of documentation, I also consent to the taking of before, during and after photographs/videos of said procedure(s) which become the technician's sole property and may or may not be used for whatever purpose deemed necessary including using pictures for social media and advertising publications.  IF YOU DO NOT WANT YOUR PICTURES POSTED ONLINE PLEASE ADVISE YOUR TECHNICIAN.  Understanding the cosmetic pigmentation procedure, the permanency of the procedure, the possible consequences of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize Brandell Hecker, RN to perform the cosmetic pigmentation procedure(s).


I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic pigmentation procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. November 26, 2021 


Please initial:

Do you agree to the fees discussed?
I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.


I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100-$300 charge depending upon the amount of work needed.


There is a possibility of an allergic reaction of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction.  Patch test: You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results, if desired.


If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigment contents are: iron oxide, lakes, alcohol, Glycerine and distilled/sterile water) I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure.


I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following the cosmetic pigmentation procedure which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is semi-permanent.


I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results.


First Clients Name

First Name*

Last Name*
First Clients Date of Birth*
First Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Second Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Third Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
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*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
No
Yes

Client Informed Consent And Procedure Chart

Please select all that apply *
Microblading (2hrs.)
Permanent Eyeliner Top AND Bottom (2hrs.)
Mircoliner (1hr.)
Permanent Eyeliner Top OR Bottom (1hr.)
Lip Blushing (3hrs)
Powder Brows
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex ? powder in gloves?
Do you take Zovirax, Valtrex or Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Are you allergic to novocaine or any caine anesthesia?
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems?
Are you taking recreational drugs?
Have you had botox or any facial injection in the last 2 weeks? If you had botox in the last 2 weeks on your forehead or in between the eyebrows we will not be able to perform the procedure.
Do you have excessively oily skin?
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)

Are you allergic to any foods or medications?
Novocain, Lidocaine or any other topical anesthetics?*
No
Yes
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*
No
Yes

If so please describe
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!