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Client Consent Form- Lip Blush

West Coast Glow LLC.

3023 Bunker Hill St Suite 102-5 San Diego, CA 92109

619-732-0220



I have been advised of the facts and matters set forth below:

I acknowledge that it is not reasonably possible for the representatives and employees of this beauty studio to determine whether I might have an allergic reaction to the products or processes used in my lip blush and I agree to accept the risk that such a reaction is possible. 

I Agree
 

I agree to follow aftercare instructions after my appointment and acknowledge that any touch-up work needed, due to my own negligence, will be done at my own expense.

I Agree

I acknowledge that infection is always possible as a result of the obtaining of lip blush, particularly if I do not take proper care of my lips. I have received aftercare instructions and I agree to follow them while my lips are healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense. 

I Agree
 

If I have any type of infection or rash anywhere on my body, I will advise my permanent makeup artist before beginning the lip blush procedure. 

I Agree
 

I acknowledge that a touch-up lip blush appointment is not included in my initial appointment, and I may need 1-2 touchups to reach my lip color & saturation goals. I understand it is my responsibility and agree to schedule touch-ups on my own within 12 weeks of the first lip blush appointment to qualify for touch-up pricing.

I Agree
 

I acknowledge that variations in color and design may exist between any lip blush color as selected by me and as ultimately applied to my body. I understand that lip blush results are not guaranteed and are dependent on many factors including genetic and environmental conditions. 

I Agree
 

I understand that if I have/had any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, or do not disclose related information to my permanent makeup artist, it may result in adverse changes to my lip blush. 

I Agree
 

I understand that lip blush is a semi-permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove it. 

I Agree
 

To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my wellbeing as a direct or indirect result of my decision to receive lip blush. I acknowledge I am over the age of eighteen and that I have truthfully represented to my permanent makeup artist that the obtaining of a lip blush is by my choice alone.

I Agree
 

By signing this agreement, I acknowledge that I have been given the full opportunity to ask all questions which I might have about the obtaining of a lip blush and that all my questions have been answered to my full satisfaction. I consent to the application of the lip blush and to any actions or conduct of the representatives and employees of the beauty studio reasonably necessary to perform the lip blush procedure. 

September 28, 2022



First Client's Name

First Name*

Last Name*

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

Pronouns *
First Client's Signature*
Second Client's Name

First Name*

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

Pronouns *
Third Client's Name

First Name*

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

Pronouns *
Fourth Client's Name

First Name*

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

Pronouns *
Fifth Client's Name

First Name*

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

Pronouns *
Sixth Client's Name

First Name*

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

Pronouns *
Seventh Client's Name

First Name*

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

Pronouns *
Eighth Client's Name

First Name*

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

Pronouns *
Ninth Client's Name

First Name*

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

Pronouns *
Tenth Client's Name

First Name*

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

Pronouns *
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
History
Check all that apply. *
I am pregnant or breastfeeding.
I currently use retinol/retinoids as part of my skincare regimen.
I am currently taking antibiotics, steroids, or prescriptions.
I am currently taking hormone therapy.
I have recently undergone radiation or chemotherapy treatments.
I have active cold sore(s).
I have had a cold sore AT LEAST once in my life.
I have PMU work (brows, freckles, lip blush, eyeliner).
I currently have an acne flare-up, broken skin, scrapes, or burns present.
I have sunburned, windburned, or severely irritated and dry skin.
I have used acid exfoliants (aha, bha, glycolic, salicylic, etc.) in the past 24 hours.
I have had a vaccine in the past 3 days.
I have used retinol, retinoids, or tretinoin in the past 3 days.
I have had a facial wax, thread, or dermaplane in the past 7 days.
I have had other facial treatments in the past 30 days.
I have had brow lamination, lash lift, or eyelash extensions in the past 6 weeks.
I have had PMU treatments (brows, freckles, lip blush, eyeliner) in the past 6 weeks.
I have had fillers, injections, or cosmetic surgery in the past 6 months.
I have used Accutane in the past 1 year.
I am currently under the care of a physician.
I have Diabetes 1 or 2.
I have a skin condition (such as Dermatitis, Psoriasis, Eczema, Keratosis Pillaris, Alopecia, Vitiligo, undiagnosed blisters or rashes, skin cancer, skin shedding or healing conditions, etc.).
I have another condition that may interfere with lip blush (such as Anemia, Hemophilia, Blood-Clotting Disorders, HIV/AIDS, Hepatitis, Psoriasis, Epilepsy, Narcolepsy, PTSD, COVID-19, Auto-Immune Disorder, Hypertension or other heart condition).
None of the above.

Please list all allergies. *

Please list all skin conditions. *

Explain all facial treatments you've had in the past 30 days and any cosmetic injections or procedures in the past 6 months. *
  
Please attach images of previous PMU work in the area.
Valid file types: JPG, GIF, PNG, and PDF
Policies Consent
I specifically acknowledge that I have read all contraindications, disclaimer, deposit/cancellations/late/covid-19/refund policies, pre-care and aftercare instructions, and agree to follow each of these as outlined on the booking website. I understand that West Coast Glow does not offer refunds on services due to the nature of their services and that they reserve the right to refuse service for any reason. I understand that cancellations less than 48 hours before the scheduled appointment will result in loss of deposit, and cancellations 48 hours or more before the scheduled appointment may reapply paid deposit if rescheduled within 30 days of first canceled appointment. I acknowledge that cancelling the rescheduled/second appointment at any point in time will result in loss of deposit.*
Yes
No
Covid-19 Disclaimer
I specifically acknowledge that I do not have any suspicion or indication of sickness, nor have I exhibited symptoms of sickness including shortness of breath, tightness of chest, fatigue, cough, headache, fever, sneezing, runny nose, change in or loss of taste, chills, body pain, etc., tested positive for COVID- 19, or been in contact with anyone tested positive in the last 10 days. I have not traveled in the past 10 days. If I have traveled in the past 10 days, I confirm that I have received a negative Covid-19 test after returning home and prior to my lip blush tattoo appointment. I agree to wear a mask upon arriving at the studio and understand that employees and staff members of West Coast Glow reserve the right to cancel my appointment without a refund if I am not strictly following Covid-19 policies. I knowingly and willingly consent to having services done during the ongoing Covid-19 pandemic and release all liability and claims from all employees and staff members of West Coast Glow for unintentional exposure or harm due to Covid-19.*
Yes
No
Photo Release Consent
I hereby give West Coast Glow consent to use photos, videos, audio, and other content of my likeness via the internet or in a public setting for informational, marketing, or educational purposes without further compensation or consideration. I understand that this content may be edited, copied, exhibited, published, or distributed and waive the right to inspect or approve the finished product in which my likeness appears. I understand that there is no time limit on the validity of this release nor is there any geographical limitation in which West Coast Glow will display this content.*
Yes
No
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 Pronouns

Pronouns *
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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