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Refined Beauty by Suwan Microblading Studio & Academy consent forms

I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. 

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmentic procedure, including, but not limited to: infections, scarring, inconsistent color, flares, and spreading, fanning or fading of pigments. Cornealabrasions are rare side effect, especially if I rub ir scratch my eyes or apply contacts too soon after eyeliner procedure. I understand the actual color of the pigment maybe modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s) of the said procedure(s).

 

There is a possibility of an allergic reaction to pigments, anesthetics, and other materials use. A patch test is advisable, however, if does not ensure a client will not have an allerigic reaction. If waived, I release the technician from liability if I develop an allergic reaction to all materials.

 

I understand the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand there may be a certain amount of pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fever blisters may occur on the lips following lip procedures on individuals prone to this problem. Fading or loss of pigment may occure Secondary infections in the procedure area rarely occurs. 

 

I understand that all instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after use. Cross contamination guidelines are strickly adhered to. Generally, infection are unusual, the area must be kept clean and following strict aftercare provided by the technician. 

 

I understand that if I have any skin treatments, laser hair removal, plasitc surgery or other skin altering procedures, it may result in adverse change to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable. 

 

Depending on the procedure(s) which I select, I accept responsiblity fo determining the color, shape, symmetry, and position of the eyebrows, eyeliner, lips, and/or the color of the camoflage. 

I have received pre and post procedure instructions and I will stricly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successtul procedure. If I am no any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores I will consult with and strickly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.

I understand that I must notify my technician if I am currently using eyelash growth serum and it may cause excessive bleeding during eyeliner procedure.

I understand and accept that the PMU procedure is a process, often requring multiple applications of color to achieve desirable results. 

I understand this procedure will result in a permanant change to my apperance.

I understnad that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s) and might be used for educational purposes and/or published online on our business website and social media accounts. I certify I have read and initialed the above paragraphs and have had explanined to my understanding this consent and procedure permit. I accpet full responsibility for the decision to have this cosmetic tattoo work donw. 

If you are a a candidate for Microblading/Permanent Makeup, please note:

- Read all the precare on the website at www.refinedbeautybysuwan.com/book-now

- Do not take Aspirin, Multi-vitamins containing Niacin, fish oils, Vitamin E 

- Do not take Ibuprofen or any pain killers unless medically necassary on the day of the procedure and 1-3 days before the procedure. Tylenol is fine. 

- Do not use skincare products containing active ingredients or any type of acids/exfoliants on your face starting 1 week prior to your proceure(s).

- Stop using Lash growth serum 1 week prior to eyeliner tattoo procedure.

- Start taking coldsore medication 5 days prior to lip tattoo procedure and continue until lips are healed. 

- If you use Accutane, you must be off Accutane for 1 year, NO EXCEPTIONS!!!

- Do not consume alcohol, caffinem, or cannabis the day before and day of procedure. 

- Avoid working out of sweating excessively right before and 10 days after procedure. 

- If you get your eyebrows waxed or tinted, it is recommended to wait at least 3 days before the procedure. 

- Antacids, high blood pressure, thyroid and anxiety medications have been reported as interfering with retention or shifting the pigments to an undersirable tone. 

- We have been advised my the AAM PMU Board to not preform any PMU procedure on those in the middle of getting their first 2 COVID -19 shots. It is advised to wait 10 - 14 days after receiving your second shot. And you should not be planning to get your booster shot withint 2 weeks of the procudure or wait 10-14 days after the booster shot has been administered. 

 

PRECAUTIONARY CORONAVIRUS LIABILITY RELEASE FORM

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

- Fever

- Fatgue

- Dry Cough

- Difficulty Breathing

- Diarrhea 

- No sense of taste and smell

- Headache/Migraine

- Body soreness

I agfree 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 been diagnosed with COVID-19 within the past 30 days.

I Agree

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 withinthe 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 Refined Beauty By Suwan Microblading Studio and Academy 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 Refined Beauty By Suwan Microblading Studio and Academy can not be held liable for any side effects that may or may not be caused by the COVID-19 vaccination due to it being new and still too many unknowns about the effects of the vaccine and PMU.

I Agree

By signing below I agree to each above statement and release Refined Beauty By Suwan Microblading Studio and Academy and thier team from any and all liability for  the unintentional exposure or harm due to COVID-19.

Your permanent makeup artist and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more throughly fight the spread of CODID-19 and other communicable conditions. 

First Client's Name

First Name*

Middle Name

Last Name*

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
First Client's Signature*
Second Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Third Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Fourth Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Fifth Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Sixth Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Seventh Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Eighth Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Ninth Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
Tenth Client's Name

First Name*

Middle Name

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

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Procedure Date

What is the date of your procedure? *
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Procedure(s) being requested (microblading, lip blush, etc)
Please check any of the following medical conditions that apply:
Dry Eye
(HSV) Cold Sores
All Hepatitis
Allergies
Alopecia
Autoimmune
Cancer(any type)/Treatment
Cataracts
Corneal abrasions
Currently wearing contact lenses
Diabetes
Easily bruised
Excessive bleeding
Eye surgery or injury
Fever blisters/Herpes
Heart problems
High blood pressure
HIV/AIDS
Keloid scars
Pregnant/Nursing
Skin Rashes (Ringworm, Psoriasis, Severe Rosacea, Eczema, Dermatitis etc)
Thyroid disease
NONE OF THE ABOVE

If you selected yes to any of the above, please specify in detail and fully understand you may be asked to request a letter from your doctor before booking a procesure. If you marked NONE OF THE ABOVE please mark NA: *

List all medications you are currently taking: *

Your Physicians Name

Your Physicians Contact info:
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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