Loading...

26 Wilson Street Guelph, ON N1H 4G5
519-994-3289 brows@meghanbarbour.ca
meghan barbour.ca

This contract states that Meghan Barbour (referred to as the technician), will provide microblading/nano/ombre brow on yourself (referred to as the client). I understand that I must fill out this form in its entirety and sign where required in order to have my services done today.

The client understands that this is a colour boost which only includes 1 appointment. The client understands that microblading/ombre nano brow is a tattoo. Permanent makeup is a process and may need more than one application to achieve the desired results. The client understands that microblading/nano/ombre brow will fade overtime and may or may not completely fade over time. Microbalding/nano/ombre brow generally last from 1-3 years but may require a touch up yearly to maintain your desired look. I understand that everyones skin is different and will accept and retain pigment differently. I acknowledge that Meghan can not guarantee the results of this procedure and I, the client accept full responsibility for the cosmetic procedure being carried out at my request.

The client has been informed by the artist of the nature, risks, and possible complications and consequences of having a facial tattoo procedure performed. The client understands that the microblading/nano ombre brow pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure including but not limited to: infection, allergic reaction, scarring, inconsistent colour, and spreading, fading, or fanning of pigments.

This service is not suitable for those who are pregnant or breastfeeding or anyone under the age of 18. Although they are rare, allergic reactions can occur. The client releases Meghan Barbour from liability if any type of allergic reaction or other reaction. If you do have an allergic reaction at anytime during or after your procedure please let me know. You may need to seek medical attention. Allergic reaction response may include redness, itching, swelling, a rash, blistering, dryness, brow hair shedding or any other symptoms associated with an allergy. Please note that some medications such as birth control or hormone therapy may alter results of this procedure.

The client understands that Meghan will be using a topical anaesthetic and that allergic reactions can occur from any anaesthetic used. Meghan also cannot accept responsibility if the areas being treated does not numb. Each individual is different according to their skin type.

The client understands that they must keep their eyes closed, lay down and be still throughout the entirety of this procedure which may be up to 2-3 hours.

The client understands that the microblading/nano/ombre brow procedure can not be performed without before and after photos. All photos taken are the property of Meghan Barbour brow+beauty and may be used for visual consultations with future clients, social media, advertising and record keeping. The client also understands that any comments/testimonials may be shared on social media and/or website.

The client acknowledges the receipt of pre-procedure information and aftercare instructions. The client has read them, has been verbally told them, understands them, and agrees to adhere to them in order to help prevent secondary infections and to get the best possible results. The client also agrees to use provided aftercare prodcuts. The client also understands that for optimal healing results that aftercare instructions must be strictly followed. The client understands that if they do not follow the attached aftercare instructions it may result in damage to the microblading or may cause scabs to fall off prematurely effecting the results of the microblading procedure. All information is also available at meghanbarbour.ca

Date: December 13, 2024 

First Participant's Name

First Name*

Last Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

First Participant's Signature*
Second Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Third Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Fourth Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Fifth Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Sixth Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Seventh Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Eighth Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Ninth Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Tenth Participant's Name

First Name*

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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Participant's 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

Please answer yes or no for the following questions:

Botox or fillers in forehead or eye area?*
No
Yes

Date done (if applicable):
Keloid formation?*
No
Yes
Other tattoos?*
No
Yes
Sensitivities to Pigments*
No
Yes
Skin Sensitivities, conditions or problems including eczema of psoriasis*
No
Yes
Currently experiencing eye infection, irritation or conjunctivitis*
No
Yes
Contact Lenses?*
No
Yes
Diabetes?*
No
Yes
Blood Disease?*
No
Yes
HIV/Aids?*
No
Yes
Cancer?*
No
Yes
Hepatitis A,B or C?*
No
Yes
Click to customize question*
No
Yes
Thyroid problems?*
No
Yes
Heart Issues or Problems?*
No
Yes
Fainting/dizziness?*
No
Yes
Respiratory issues or disease?*
No
Yes
Haemophiliac?*
No
Yes
Pregnant or nursing?*
No
Yes
Using Accutane or ever have?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Using acids or chemical peels?*
No
Yes
Using Retina-A or Retinol?*
No
Yes
Trichotillomania?*
No
Yes
Any Facial Construction Surgeries?*
No
Yes
Taking Blood Thinners Such as Aspirin, Coffee, Tea, Coumadin, Alcohol, Ibuprofen, Vitamin E or Omega-3?*
No
Yes
Any Medical Concerns?*
No
Yes
Any medications including vitamins*
No
Yes
Any other diseases or medical conditions?*
No
Yes

If yes please list
Any allergies or sensitivities?*
No
Yes

If yes please list

Addition comments/information:

I understand and agree to the pricing and I am responsible to pay the full amount agreed upon. I understand that this includes a single appointment only. I understand that if I need additional appointments that there may be a fee.

I understand the risks and complications of microblading and I release my technician from all liability associated with this procedure. I agree to and understand all information in this waiver. By signing this agreement I confirm that the information I have given is correct. 

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!