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Permanent Cosmetics Intake & Consent Form

 

 


This form provides information about permanent cosmetics, semi permanent cosmetics and tattooing. You are encouraged to carefully review the information provided to make an informed decision as to whether to undergo the procedure. Permanent cosmetics, semi permanent cosmetics (microblading, microshading, powder brow, nano brow, permanent eyeliner, lip blushing) involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing. Initially the color will appear more vibrant or darker compared to the end result. Usually within 7-10 days the color will fade 40-50%, soften, and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched up within 12 months depending on skin type, lifestyle and pigments color that is used. All instruments that enter the skin or encounter body fluids are disposable and disposed of after each use. Cross contamination guidelines are carefully adhered to. 


READ THOROUGHLY

CLIENTS WILL NOT BE ABLE TO HAVE ANY COSMETIC PERMANENT MAKEUP, MICROBLADING OR TATTOOING PROCEDURE COMPLETED IF ANY OF THE FOLLOWING APPLY TO YOU.

  • If you are pregnant or breast feeding you may not receive this service.​
  • If you are taking any type of blood thinning medications. 
  • If you have any history of keloids you have not receive this service.
  • If you plan on using a tanning bed regularly you do not want to receive this service because the tanning bed will 100% affect your results. No amount of SPF or covering your face will ever prevent this, it is inevitable.
  • If you have Lupus or have an autoimmune disease you must have a doctor’s note to book this session. You must have medical clearance.

 

POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS

PAIN: there is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.

INFECTION: although rare, there is a risk of infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care” sheet for instructions on care.

UNEVEN PIGMENTATION: this can result from poor healing, infection, bleeding, or many other causes. Your follow up appointment will likely correct any uneven appearance.

ASYMMETRY: every effort will be made to avoid asymmetry, but our faces are not symmetrical. Adjustments may be needed during the follow up session to correct unevenness.

EXCESSIVE SWELLING OR BRUISING: some people bruise and swell more than others. Ice packs may help, and the bruising and swelling typically disappear within 1-5 days. Some people don’t bruise or swell at all.

ANESTHESIA:topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.

ALLERGIC REACTION: there is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7 day patch test to determine this

***The alternative to these possibilities is to use cosmetics and not undergo the cosmetic permanent make up procedure.***

 

CONSENT FOR COSMETIC PERMANENT MAKE UP PROCEDURE

Please read and sign if all following statements are true.

  • I am currently not under the influence of ant drugs or alcohol
  • I have not been out of the country within the last 14 days.
  • I have not experienced any symptoms or ailments for 14 days
  • I have not been around anyone diagnosed with COVID19 for the past 30 days
  • I am NOT pregnant
  • I do not currently take nor have taken Accutane within the last 12 Months.
  • I have not had Botox and/or other cosmetic filler procedures within the past two weeks.
  • I have not had any surgery of any kind in the past 6 months
  • I have not taken any blood thinning medication with the past 72 hours nor have I taken aspirin with the past 24 hours.
  • Aftercare instructions have been explained to me and are attached to this consent form. A written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will contact my technician.
  • I will contact my physician if I notice any infection beginning to form.
  • I understand a certain amount of discomfort is associated with the procedure and that swelling, redness and bruising may occur.
  • I understand that Retin A, Renova, Alpha Hydroxy and Glycolic acids must Not be used on the treated areas. This will alter the color.
  • I understand that the sun, tanning beds, pools, some skin care products and medication may affect my permanent makeup
  • I accept the responsibility for explaining to my technician my desire for specific colors, shape and position for any procedure done today.
  • I understand that implanted pigment may change or fade over tine due to circumstances beyond the salon’s control and I will need to maintain the color with future applications and a touch up session in 4-8 weeks.
  • I acknowledge that the cosmetic permanent make up procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedure such as: infection, misplaced pigment, poor color retention and hyperpigmentation.
  • I have been quoted the cost of today’s appointment which includes (1) touch up session within 6 weeks following today’s appointment. After 6 months, a fee will apply for any further touch-ups. There will be no refund for this elective procedure.
  • I acknowledge that I am at least 18 years of age and I certify that I have read or have had read to me the contents of this form. I understand the risk and alternatives involved in this procedure. I have had the opportunity to ask questions and all my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Whitney Hughes to perform the cosmetic permanent make up procedure on me.
  •  I hereby release Whitney Hughes from any liability arising from the risks that are known and /or inherent in the cosmetic permanent make up procedure.

If appointment is canceled less than 48 HOURS prior to the appointment a $75 fee will need to be paid via Credit/ Debit card, Apple Pay, Venmo, by Invoice when canceling.

Today's date: December 22, 2024

 

 


First Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
First Client's Signature*
Second Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Third Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Fourth Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Fifth Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Sixth Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Seventh Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Eighth Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Ninth Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Tenth Client's Name

First Name*

Last Name*

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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Client'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.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Tell us how you heard about Beyond Beauty by Whitney!

Who Referred you?
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

Optional Photo Release Consent
Whitney Hughes would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc.

Please indicate YES or NO whether you consent to the use of your photos for advertisement purposes.*
No
Yes

ALLERGIC REACTION

Please select yes or no to waive the patch test*
No
Yes

CLIENT INFORMATION

Please select yes or no for the following

History of MRSA*
No
Yes
Bleed easily/ Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or breast feeding*
No
Yes
Cancer*
No
Yes
Tumors/ Growths/ Cysts*
No
Yes
Difficulty numbing during dental procedures*
No
Yes
Autoimmune disorder*
No
Yes
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Eczema*
No
Yes
Herpes*
No
Yes
Oily skin*
No
Yes
Use Accutane for acne treatment, past or present?*
No
Yes
Botox*
No
Yes
Tan by booth or sun*
No
Yes
Chemical Peel*
No
Yes
Have you consumed drugs or alcohol within the last 48 hours*
No
Yes
Allergic to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene, Glycol, Neosporin, Vitamin E acetate*
No
Yes
Did you undergo any surgery in the last 14 days*
No
Yes
Allergic to metals, such as nickel, titanium, iron?*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acids, Alpha-Hydrooxy acids*
No
Yes
Do you exfoliate your skin weekly*
No
Yes
Do you Fully understand that any dissatification/ concern must come DIRECTLY to your artist WHITNEY HUGHES nor any of its artists are to be slandered on Any public forum whatsoever, for any reason at all, or legal action will be taken. Whitney Hughes is not legally responsible for any later disapproval of agreed upon shape, strokes, services, etc. You are electing to have microblading or Any service done at your own risk and reward*
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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