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Framed Beauty Company PMU Consent Form

My Salon Suites (Ballantyne)

11930 Providence Rd. W Suite C-2

#301

Charlotte, NC 28277

This document outlines and confirms your understanding, safety and health protocols of all permanent makeup services and includes information regarding:

  • Contraindications
  • Possible Risks, Hazards, or Complications
  • Policies
  • Care and Maintenance
  • Consent & Release Agreement
  • Photo Release Agreement
  • Coronavirus Liability Release


Thank you for choosing Framed Beauty Co. for your permanent makeup experience.

Client's information and signature is required according to North Carolina's Department of Health and Human Services Division of Public Health and driver's license information is required to verify age for services (18+ years old). 

Please read the following information and instructions to ensure the best results for your treatment. 

PRE-CARE INSTRUCTIONS:

7 days prior to your appointment, discontinue:

  • Vitamin E
  • Fish oil supplements
  • Turmeric 

48 hours prior to your appointment, it is very important to refrain from the following:

  • Alcohol
  • Any aspirin products, Ibuprofen, and Aleve

24 hours prior, please avoid:

  • Caffeine, energy drinks, soda, and coffee

Not having caffeine in your system will help you to relax, as well as, relax the facial muscles where we will be working.

All of the products mentioned above will cause excessive bleeding and will negatively affect the longevity of your semi-permanent makeup application. In some cases, the application may need to be prematurely stopped.

Lip Blush Treatment:

If you have a history of cold sore or fever blisters, we highly recommend taking Lysine, Valtrex or Zoviraz tablets for 5 days prior and for 5 days after your appointment. 


 

CONTRAINDICATIONS

I confirm that I have accurately filled out the Client Intake Form to the best of my knowledge and DO NOT have any current or existing contraindications.

We are NOT able to perform any treatment on clients:

  • Under the age of 18 years old
  • Pregnant or nursing
  • With any heart conditions, epilepsy, or cancer
  • With Autoimmune Diseases (HIV/AIDS, Hepatitis Lupus, Rheumatoid Arthritis)
  • With any skin conditions present on/near the treatment area unless medically cleared by a doctor: Keloid, Vitiligo, Seborrheic Dermatitis, Psoriasis, Eczema, Rosacea, Keratosis Pilaris
  • Using antibiotics, Accutane or steroids

If you have any skin conditions, a note from your dermatologist will be required to confirm that the treatment is safe to be performed. 

I Agree

I understand that at any given time, I may be required to provide a Doctor’s note for any health conditions such as:

  • Skin Conditions
  • Thyroid Disease
  • Cancer
  • Diabetes

I Agree
 

POSSIBLE RISKS, HAZARDS & COMPLICATIONS

Allergic Reactions - Although rare, are possible and can occur with anesthetics (ingredients may contain lidocaine, tetracaine, epinephrine), pigments, and dyes used during PMU treatments. 

Pain & Numbness - Each client responds to anesthetics differently according to skin type. You can expect to experience some discomfort although clients report little to no pain. 

Uneven Pigmentation - Results from poor healing, infection, bleeding or many other causes. Final adjustments can be made at the touch-up session.

MRI - Some pigments may contain inert oxides. You must inform the MRI technician of any cosmetic tattoo treatments. A low level magnet may be required if a scan is necessary.

Possible Infections - Infections are VERY RARE. We use only sterile disposable tools, medical grade disinfectants and adhere to all health protocols/guidelines. 

It is highly crucial to follow aftercare instructions properly to prevent any adverse reactions or infections. 

 

CARE & MAINTENANCE

It is vital to follow aftercare instructions to ensure your best results, proper healing and color retention. 

Aftercare instructions will be communicated verbally in detail at the end of your treatment, included in your aftercare kit and is also available on our website. 

 

What to expect for the first 10 days after the PMU treatment

First 2 days: The color will be a little dark. Slight swelling, thickness, and/or redness for 1-2 days following the treatment.

After about 6 days: The color will appear to be very light

After 10 days: The color will resolve itself to its appropriate shade

 

PMU General Healing Expectations

●     The color will appear softer once completely healed. It is normal to lose approximately 30-50% of the color during the healing process.

●     Complete healing takes 30 - 45 days.

●     Your touch-up appointment (after 4-8 weeks) will perfect your look adding to any areas if needed, and going over any faded areas.

●     Your brows and/or lips will appear darker and 10-15% wider than they will be when completely healed.

●     Natural exfoliation will cause the excess pigment surrounding the treatment area to flake away and narrow the width of your brows and/or lips.

●     Don’t be concerned that your eyebrows and/or lips will initially appear darker and heavier in size than you desire, this is all part of the healing process.

 

Angel Tattoo Removal

The first removal product specifically designed for eyebrows. 

A non-laser, manual technique, designed to safely remove 99.9% of all tattoo pigments from the skin. In particular, pigments from permanent makeup. 

Angel Removal uses active ingredients from acids of antioxidant fruits to attract pigment toward the skin's surface to be eliminated. 

Great for existing PMU that has changed color, is overly saturated/dark and for correction. 

Angel Removal General Healing Expectations

●  Results can be seen in 2-3 weeks.

●   Pigment can continue to leave the area for up to 30 days.

●   Depending on the depth and color of the existing tattoo, more than 1 session may be required to see optimal results.


I understand that permanent makeup or removal results are not guaranteed under any circumstances. For permanent makeup, pigment implantation works differently on each individual. Those with large pores, acne, oily skin or thin and sensitive skin tend to have more difficulty retaining pigment. 

I Agree

I understand that Angel Tattoo Removal is a non-laser, manual technique that uses acids from antioxidant fruits to safely remove pigment from the skin. 

I Agree

I understand that Microblading is a very natural look and that eyebrow pencil or powder may still be needed. 

I Agree

I understand that the artist will advise the best treatment for my skin type and lifestyle. If I decide to chose a treatment outside of the recommended treatment by the artist, results may not be optimal. 

I Agree

I understand that a complimentary 4-8 weeks touch-up session is included for all new permanent makeup applications (Microblading, Combo Brows, Powder Combo, Powder Brows, Lip Blush) to make any final adjustments. If I decide to schedule my touch-up after 8 weeks, a fee will apply. 

I Agree

I understand that the artist, has no control over what occurs during the healing process and additional touch-ups or sessions may be necessary to obtain optimal results (fee applicable).

I Agree

I understand that if I have existing permanent makeup that needs correction or is being covered up, additional touch-ups or sessions may be necessary to obtain optimal results (fee applicable).

I Agree

I understand that I will go through a healing process and may experience some patchiness and unevenness while the color continues to stabilize. The entire healing process can take up to 45 days and I understand that towards the end of my healing the pigment will settle and heal more true to color. But, can vary according to skin tones, skin type, age and skin conditions. 

I Agree

I understand that 50% of my results depend on how well I follow aftercare instructions post-treatment.

I understand that failure to follow aftercare instructions may result in permanent damage to my skin, scarring, or may prevent pigment from settling. I agree to keep the treatment area clean, and to follow aftercare instructions.

I Agree

I understand that my treatment is semi-permanent and can last from 1-3 years depending on my skin type, regimens, lifestyle, certain medications and how well I follow aftercare instructions. Therefore, semi-annual or annual touch-ups are needed to boost color and definition. 

I Agree

I understand that products such as Retinol/Retinoids, Retin-A, Tretinoin, glycolic, salicylic, lactic acid, any anti-againg products, sun exposure, tanning beds, and certain medications can affect my permanent makeup or treated area. 

I Agree

 

POLICIES

I understand that there is a NON-REFUNDABLE but transferable deposit to secure my appointment, which will be applied toward the overall cost of my treatment. 

I understand that a 72-hours notice is required to reschedule my appointment. Failure to give a 72-hour notice will forfeit my deposit, and an additional $75.00 NON-REFUNDABLE deposit will be required to secure another appointment. 

The remaining balance will be processed on the day of your treatment. We accept payments by Visa, MasterCard, American Express, Cash or Debit Cards, Zelle, Venmo, and CashApp. No Checks accepted. 

If I decide to cancel or fail to show up to my appointment, I will automatically forfeit my deposit. If I am more than 15 minutes late, my appointment may need to be rescheduled. 

I UNDERSTAND THAT ALL TRANSACTIONS ARE FINAL. NO REFUNDS WILL BE ISSUED. 

I understand that the artist, Kathy Nguyen, can release me as a client at any time if I am not compliant with the policies.

 

CONSENT & RELEASE AGREEMENT

I am over the age of 18, am not under the influence of drugs or alcohol, I am not pregnant and desire to receive permanent makeup services. If I am actively nursing, I agree to pump and dump for 48 hours after my appointment. The general nature of cosmetic tattooing, as well as the specific treatment performed has been explained to me. 

I Agree

I have been informed of the nature, risks, and possible complications and consequences of cosmetic tattooing. Permanent makeup services carries known and unknown complications and consequences including but not limited to: infection, scarring, inconsistent color, and spreading or fading of pigments. 

I Agree

I accept the responsibility for determining the color, shape, and position of the treatment as agreed during the consultation. 

I Agree

I understand the actual color of the pigments may be modified slightly due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not a science but an art. 

I Agree

Upon completion of the PMU treatment, I understand that there may be swelling and redness of the skin, which will subside within 1-2 days. In some cases, slight bruising may occur. 

I Agree

I certify that I have read the consent form in its entirety. I understand the risks involved in this treatment(s) and have been given the full opportunity to ask any and all questions about cosmetic tattooing, Angel Removal, its process and any risks involved from Kathy Nguyen. Therefore, I release any and all legal liability.

I Agree

 

PHOTO RELEASE

I understand that the taking of before and after photographs might be used for educational purposes and/or published online on our business website and social media accounts. If you are not comfortable with your photos being published, please notify us at your appointment. 

I understand that the taking of before and after photographs is required for professional and confidential files.

I Agree

CORONAVIRUS LIABILITY RELEASE

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below:

Symptoms of COVID-19 include:

  • Fever
  • Fatigue
  • Dry Cough
  • Difficulty Breathing
  • Diarrhea
  • Headache/Migraine
  • Loss of taste and/or smell
  • Body Soreness

I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

I Agree

I affirm that I, as well as all household members, have not knowingly been diagnosed with COVID-19 within the last 30 days.

I Agree

I affirm that I, as well as all household members, have not traveled outside the United States or to any state or city outside of our own that is or has been considered a "hot spot" for COVID-19 infections within the last 30 days. 

I Agree

I understand that Framed Beauty Company LLC can not be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. 

I Agree

I understand that a mask is not required but recommended upon entering the studio and during the time I am at Framed Beauty Co.

I Agree

I understand that Framed Beauty Company LLC cannot be held liable for any side effects that may or may not be caused by the COVID-19 vaccination and the unknowns about the effects of the vaccine and PMU. 

I Agree

Framed Beauty Company is following these enhanced protocols to prevent the spread of COVID-19. 

Additional time is included between appointments to prevent client contact with each other. 

Guests accompanying those scheduled for service are no longer allowed, and no children are permitted during appointments. 

Social distancing is required and clients may be asked to wait outside or in their car.

PLEASE NOTIFY US IF YOU HAVE OR PLAN TO BE VACCINATED WITH THE COVID-19 VACCINATION. WE HAVE BEEN ADVISED BY THE AAM PMU BOARD TO HALT ALL PMU TREATMENTS IN BETWEEN SHOTS, AWAITING 10-14 DAYS AFTER SECOND SHOT TO PERFORM PMU TREATMENTS. 

By signing below, I agree to each above statement and release Framed Beauty Company LLC from any and all liability for the unintentional exposure or harm due to COVID-19.

September 29, 2022















First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
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 or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Confidential Medical Profile
What type of skin do you have? *
Dry
Normal
Combination
Oily
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you pregnant?*
No
Yes
Are you nursing?*
No
Yes
Do you have Epilepsy/Seizures of any kind?*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes, when and what area(s)?
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain?
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Have you had chemical or laser peels?*
No
Yes

If yes, when?
Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?*
No
Yes
Do you take Antidepressants or mood altering medication?*
No
Yes
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently using Retin-A, Retinol/Retinoids, Tretinoin, or Alpha Hydroxyl skin care products?*
No
Yes
Do you wear contact lenses?*
No
Yes
Have you had caffeine products in the last 24 hours?*
No
Yes
Have you consumed alcohol in the last 48 hours?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you presently taking Vitamins A, E or fish oil in any form?*
No
Yes
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Alopecia?*
No
Yes
Do you have Trichotillomania?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Diabetes?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes

For your safety, please inform us of any medical conditions:
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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