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DISCLOSURE AND CONSENT FORM

ERICA MOYER BROW + BEAUTY/ MICROBLADING

We appreciate your patronage. Please read and fill out this Disclosure and Consent form completely, making certain that all information is filled out correctly and to the best of your knowledge.

By signing below, I acknowledge, understand and agree that:

  • I have read over the website, pre-requirements, aftercare, and what makes a good candidate thoroughly before booking. I understand that in order to book online I agreed to the terms and conditions that I am properly prepared and a good candidate for Microblading. I understand that if I arrive to my session and Microblading cannot be performed a cancellation fee will be charged. 
  • Erica Moyer Brow + Beauty does not practice medicine, does not accept health insurance, and have made no representation to the contrary.
  • The information provided on this form is accurate and complete to the best of my knowledge, and that Erica Moyer Brow + Beauty is not responsible for complications and/or problems arising from any incorrect and/or omitted information.
  • Some individuals will have complications related to semi-permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks.
  • Erica Moyer Brow + Beauty will use the information provided above to assess my suitability for the proposed micro-pigmentation and/or microblading services.
  • Erica Moyer Brow + Beauty reserves the right to refuse service(s) when perceived complications and/or risks are deemed unethical and/or too risky based upon our professional experience.

(Please initial the line next to the number after you clearly understand each statement)

1. I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.

 

2. I acknowledge that complications as a result of semi-permanent (microblading/micro- pigmentation) makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications. 

 

3. I realize that my body is unique and that hyper-pigmentation (darkening of the skin) or hypo- pigmentation (absence of color in the skin), or scarring is a possibility and Erica Moyer Brow + Beauty can't predict how my skin may react as a result of the procedure. 

 

4a. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today

4b. IF YES, I have received Erica Moyer Brow + Beauty mandatory approval to schedule a touch up or correction session from previous artist's work.  

4c. IF YES, I understand that correcting or touching up micro-pigmentation or microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Erica Moyer Brow + Beauty has no control. I understand that additional appointments after the initial and follow-up appointments may be required, and will be billed at Erica Moyer Brow + Beauty standard rates. I understand that Erica Moyer Brow + Beauty cannot predict the results in advance and cannot guarantee and has not represented that the results will be, as I desire. I understand and fully accept the risks associated with this procedure.

 

5. I acknowledge that the procedure may result in a long lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.

6. I understand that implanted pigment can turn color or fade over time due to circumstances beyond the control of Erica Moyer Brow + Beauty. The original color may be altered by things such as sun exposure, tanning beds, skin care products (especially anti-aging products like Retinols, AHA, BHA, etc.), pools, salinity levels of each person’s eyes/skin, general health and other factors. I understand that I will need to maintain the color with future applications. 

7. I understand that future skin altering procedures such as laser treatments, plastic surgery, and/or injections may alter and degrade my semi-permanent makeup, and that I must inform any future service provider that I have had micro-pigmentation or microblading applied. I understand and accept that such changes are not the fault of Erica Moyer Brow + Beauty. I further understand that such changes or degradation in my appearance may not be correctable through further semi-permanent makeup procedures. 

8. I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance. 

9. I acknowledge that obtaining the semi-permanent makeup is my choice and my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of Erica Moyer Brow + Beauty reasonably necessary to perform the procedure. 

10. I understand that I will have the opportunity to approve the design and color of the semi- permanent makeup to be applied, and I accept responsibility for the same. 

11. I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of Erica Moyer Brow + Beauty. 

13. I have been given the full opportunity to ask any and all questions which I might have about obtaining semi-permanent cosmetic procedures from Erica Moyer Brow + Beauty, and that all of my questions have been answered to my full and total satisfaction.

 

15. I understand that there will be NO refunds after treatment of this elective procedure(s). 

 

16. For some skin types, semi-permanent makeup may be a multi-session process. In addition to your initial application, a follow-up appointment is recommended. At the follow-up appointment I will determine if a touch-up to the initial application is required. You must schedule your follow-up appointment within 30 days after the initial procedure. 

 

17. It is the responsibility of the client to contact Erica Moyer Brow + Beauty online booking within 30 days of initial application to schedule follow-up session. (Up to 3 weeks may be needed to schedule an appointment so please schedule as far in advance as possible.) 

 

18. If client has only one application, then decides 3-6 months later that he/she wants second application, the client WILL be charged for the appointment according to the current fee schedule in place. (Touch-up application should be no more than 4-6 weeks, and absolutely NO LONGER than 8 weeks from the initial application.) 

 

19. I acknowledge the receipt of written instructions advising me of the proper care of my procedure(s) and I recognize the absolute necessity for following these instructions. 

 

20. For cancellation or rescheduling of initial appointment, I acknowledge and accept, that I, the client, will notify Erica Moyer Brow + Beauty 24 hours prior to scheduled appointment, otherwise I will be charged $100 for late cancellation or no shows. 

 

21. The fee for semi-permanent makeup services has been explained to me and has been agreed upon. I understand the total fee for services rendered is due prior to completion of the initial procedure(s) and that there will be separate fees for any future modification of the design(s) or major color change(s). 

 

22. I agree that Erica Moyer Brow + Beauty liability is limited to the cost of the procedure performed unless it is proven that Erica Moyer Brow + Beauty was negligent in the performance of duties. In the event of disputes that cannot be amicably resolved, Erica Moyer Brow + Beauty and client agree to a binding arbitration between the two parties to resolve disputes. 

 

23. I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. 

 

Date: August 19, 2022 

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Second Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Third Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fourth Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Fifth Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Sixth Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Seventh Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Eighth Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Ninth Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Tenth Client Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Parent or Guardian's Information
11. I have previously had micro-pigmentation, microblading, or permanent make-up performed by someone other than Erica Moyer Brow + Beauty on the same area that I am asking Erica Moyer Brow + Beauty to work on today*
No
Yes
12. I understand that if I have had previous permanent eyebrow tattoo or Microblading from another artist permission to book a session from Erica Moyer Brow + Beauty is mandatory and I have received permission to book a Microblading session.*
No
Yes
13. [Optional/Requested] I consent to Erica Moyer Brow + Beauty using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contactin Erica Moyer Brow + Beauty in writing, which will then discontinue use of said photo(s).*
No
Yes
15. If you have previously had microblading performed by Erica Moyer Brow + Beauty, has your medical history changed since you last filled out Erica Moyer Brow + Beauty's Medical Profile form?*
No
Yes

Medical Profile 

Have you ever had any semi-permanent makeup procedures before?*
No
Yes

If YES, please specify.
Have you had any aspirin or blood thinners in the past week?*
No
Yes
Are you allergic to any metal?*
No
Yes
Have you taken any mood altering drugs within the last 8 hours?*
No
Yes
Are you on any immunosuppressive medications such anti-inflammatories or steroids?*
No
Yes
Do you have a history of cold sores, herpes, or fever blisters?*
No
Yes
Are you allergic to topical antibiotic preparations or desensitizers? Are you sensitive/allergic to latex?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you currently taking any vitamins a or e in any form?*
No
Yes
Are you pregnant or nursing? IF YES, I understand that Microblading cannot be performed.*
No
Yes
Do you have problems healing?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Have you experienced any problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes

**A "yes" answer does not indicate you are not an acceptable candidate for semi-permanent cosmetics. It may simply be information that is valuable as your technician, as each person's body is unique. It may indicate that based on any health conditions that affect healing; it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. 


Also, please provide clarification for any "yes" answer you listed above:

List any/all medications you are currently taking:
*Please Select Any Of The Following Which May Pertain To You
Heart Conditions
Diabetes
Refractive Eye Surgery
Epilepsy/Seizures
Hepatitis/ Jaundice
Allergies To Makeup
Stroke
Glaucoma
Shortness Of Breath
HIV
Accutane Treatment
Dry Eyes
Chest Pains
Alopecia
Trichotillomania
Keloid/Hypertrophy Of Scars
Autoimmune Disorder
Cancer (Any)
Kidney Disease
Tendency To Develop Fever
Blisters On The Lip
Ocular Herpes
Hyperpigmentation
Hypopigmentation
Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above:
Have you received botox within the past two weeks?*
No
Yes
Have you received any chemical peels or lasers for 60 days prior?*
No
Yes
Have you received microneedling for one month prior?*
No
Yes
Have you used any retinol or anti-aging creams or wash for 2 weeks prior?*
No
Yes

If you have answered "Yes" to any of the questions above, please contact Erica Moyer Brow + Beauty to reschedule your Microblading session.

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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