Loading...

CLIENT CONSENT FORM

I am over the age of 18 and desire Luxury Brow KC to perform the elective cosmetic pigmentation procedure.  I understand that this procedure is for cosmetic purposes only and not for health reasons. I am aware that no guarantees have been made to me concerning the results of the procedure(s).

I also understand that the permanent skin 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. 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 permanent skin pigmentation procedure, 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 purposes 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 permanent skin 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 Luxury Brow to perform the permanent skin 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 procedure(s) which is to be performed at my request according to this consent.

Please intial:

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 retain of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. 

Patch test: If you are concerned about potential reactions to pigment, please make a seperate appointment for a patch test.  By initialing, you are bypassing the patch test and assume responsability for any reactions that may occur. 

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

Laser treatments or ANY kind of facial injections may also compromise your permanent cosmetic makeup application.  You must wait 3 weeks after any facial injections before receiving cosmetic pigmentation.

I certify that I have read and initialed the above paragraphs and have had explained to me fully and 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.

Today's Date: November 25, 2020

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
First Client's Signature*
Second Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Third Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Fourth Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Fifth Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Sixth Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Seventh Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Eighth Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Ninth Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Tenth Client's Name

First Name*

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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
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

Client Informed Consent And Procedure Chart

Please Check *
Microblading (2hrs)
Permanent Eyeliner (2hrs)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
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?
Do you take Zovirax, Valtrex or Famvir? If you are prone to cold sores or have the herpes virus, it is advised that you begin the antiviral drug BEFORE the lip blushing procedure.
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, benzocaine, lidocaine or tetracaine? Topical anesthetic is always used during ALL cosmetic tattoo procedures.
Are you prone to, or have any keloid scars?
Do you wear contact lenses, have implants or any eye problems? *please remove contacts before eyeliner procedure
Are you taking recreational drugs?
Have you had Botox or any facial injections in the last 3 weeks? You must wait 3 weeks after any facial injections before receiving any cosmetic tattoo procedures.
Do you have excessively oily skin? If you have oily skin, it is not recommended that you receive microblading, but to schedule powder brows.
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Alopecia
Cancer surgery
Dermabrasion
Herpes infections
Chronic/ migraine headaches
Chronic eye conditions
Recurrent heart palpitations
Elevated blood pressure
Chemical peels
Are you presently taking any medications?*
No
Yes
Are you allergic to any foods or medications?*
No
Yes
Are you presently under a physician's care?*
No
Yes

What for?
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN**
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
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:
Acutane
Anti-anxiety drugs
Antibiotics
Anticoagulants
Arthritis
Aspirin/tylenol/ibuprofen (do not take 48 hrs. before procedure)
Blood pressure meds
Blood thinners (do not take 48 hrs. before procedure)
Diabetic meds
Heart meds
Hormones
Insulin injections
Meds for depression
Meds for mood change
Meds for mood change
Pain or headache meds
Preparations
Seizure meds
Steroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever Blisters
Glaucoma
Gortex
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
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!