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LUXURY BROW + SKIN CLIENT CONSENT FORM AND WAIVER

I am over the age of 18 and desire Luxury Brow + Skin 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 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 + Skin to perform the permanent skin pigmentation procedure(s).


I agree to the fees discussed and fully understand that a cancellation 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 than 48-hour notice. The entire staff is dedicated to client satisfaction. Luxury Brow + Skin employs a no-refund policy, and I am aware of this. 


I absolutely understand that this procedure is a process and that subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to a charge of $100-$300, depending upon the amount of work needed. There is a possibility of an allergic reaction from 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 separate appointment for a patch test. By initialing, you are bypassing the patch test and assume responsibility for any reactions that may occur. 


If waived, I release Luxury Brow from liability if I develop an allergic reaction to the pigment. (Pigment contents include: iron oxide, alcohol, Glycerin and distilled/sterile water). I 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 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.


Today's Date: May 24, 2025

First Client Name
First Name*
Last Name*
Phone*
First Client Date of Birth*
Date of Birth
First Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
First Client Signature*
Second Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Second Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Third Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Third Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Fourth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Fourth Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Fifth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Fifth Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Sixth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Sixth Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Seventh Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Seventh Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Eighth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Eighth Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Ninth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Ninth Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
Heart condition
Heart disease
Heart murmur
Hepatitis
History of seizures
Hypertension
Jaundice
Seasonal hay fever
Tenth Client Name
First Name*
Last Name*
Phone*
Client Date of Birth*
Date of Birth
Tenth Client Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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*
Date of Birth
Parent or Guardian's Information

Client Informed Consent and Procedure Chart

Please Check *
Microblading (2 hours)
Permanent Eyeliner (2 hours)
Lip Blushing
Powder Brows
Stardust Eyeliner (combination of eyeliner with eyeshadow)
Check if the answer is 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 have you 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 you had any, keloid scars?
Do you wear contact lenses, have implants, or have 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 instead you should schedule the Powder Brows appointment.
Do you have any skin condition such as eczema, rosacea, etc. ON YOUR FACE (not your body)?
Do you have alopecia?
Have you had cancer surgery?
Have you ever had dermabrasion?
Have you ever had a herpes infection?
Do you have chronic/migraine headaches?
Do you have any chronic eye conditions?
Do you have recurrent heart palpitations?
Do you have elevated blood pressure?
Have you ever had a chemical peel?
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
If yes, please explain.
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 A PERMANENT MAKEUP PROCEDURE.*
No
Yes
If so, please describe:
If you are now taking or recently have taken any of the following, please select below. You may need a physician's release prior to your procedure:
Acutane
Anti-anxiety medications
Antibiotics
Anticoagulants
Arthritis medications
Aspirin/acetaminophen/ibuprofen (do not take 48 hours before procedure)
Blood pressure medications
Blood thinners (do not take 48 hours before procedure)
Depression medications
Diabetic medications
Heart medications
Hormones
Insulin injections
Mood-change medications
Pain or headache medications
Preparations or compounds
Seizure medications
Steroid preparations or compounds
Please select if you have or recently had any of the following. You may need a physician's release prior to your procedure:
Anemia
Any breast problems
Asthma
Blurred vision
Chronic sinus congestion
Chronic skin problems
Collagen injections
Diabetes
Fever blisters
Glaucoma
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.


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