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Microblading/Lip Blushing Consent Form


CONSENT

I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and I consent to receiving the microblading procedure. I have been informed and it was explained to me the general nature of cosmetic tattooing as well as the specific procedure to be performed.

I have been informed of the possible risks and consequences of microblading and I understand that there might be complications and consequences associated with this procedure, such as: infection, scarring, or inconsistent color.

I understand that this cosmetic procedure is not fully permanent and might result to fading in time. I have likewise received and will strictly adhere to procedural instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my responsibility.

I have been advised to do a patch test to identify any allergic reaction to any medicine or anesthetics. Should I waive for the test, I release the technician from liability if I develop an allergic reaction to any of the procedure.

I acknowledge that some changes might not be corrected in case I undergo other  laser hair removal, plastic surgery or other procedures.

I understand that photographs taken for comparison of the before and after procedure are part of the said procedure.

I accept full responsibility for the decision to have this microblading procedure done. The cost for touch-up’s after this first procedure are not included.

 

Date: November 30, 2022

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
First Client's Signature*
Second Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Third Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Fourth Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Fifth Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Sixth Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Seventh Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Eighth Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Ninth Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
Tenth Client's Name

First Name*

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

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
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.
Contact in case of Emergency

First Name

Last Name

Address


Street Address

Street Address

City

State / Province

Postal / Zip Code

Phone Number

Second Phone Number
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*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Medical History Inquiry

Have you had or currently have any of the following

Currently Pregnant*
No
Yes
Currently Breastfeeding*
No
Yes
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)*
No
Yes
Had undergone Botox treatment*
No
Yes
Has or any family history of Diabetes*
No
Yes
Had Facelift Surgery*
No
Yes
Has Hepatitis A B C D*
No
Yes
Had Forehead/Brow Lift*
No
Yes
History of Alcoholism*
No
Yes
Has a Heart Condition*
No
Yes
Had a Brow Lash Tinting*
No
Yes
Has Autoimmune disorder*
No
Yes
Has Oily Skin*
No
Yes
Has, had, or any family history of having Cancer*
No
Yes
Had undergone Chemotherapy/ Radiation*
No
Yes
Taking or have taken acne treatments in the past 3 months*
No
Yes
Has a history of fever blisters/ cold sores?*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications*
No
Yes
Allergies to metals, food, etc,*
No
Yes
Any diseases other than listed here*
No
Yes
Do you use facial care treatments?*
No
Yes

Please list down any medications you are taking
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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