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Lip Blush Treatment Waiver

What is Lip Blush?

Lip blushing is a type of semi permanent cosmetic tattooing procedure achieved by depositing pigments into your lips using a permanent make-up machine. Lip blushing focuses on altering both color and shape to create younger-looking lips. There is only so much manipulation that can be done when it comes to contouring the lips, this will be explained in more detail at our appointment. Both lip shape and color can be altered with Lip Blushing, but we must stay within the vermillion boarder and lip tissue to get the best possible results. Lip Blushing is not meant to replace traditional lip fillers, although the appearance of the lips can be enhanced with this technique!

What is the typical cost for Lip Blushing?

Remember you get what you pay for! Competitors may charge differently, but this requires a higher price tag, lips frame the face so it's critical they are perfect.

Free optional consultation (Only absolutely necessary if you have previous tattooing on your lips)


Lip Blush treatment for Lips- $500, consult not required **DISCLAIMER: We do NOT provide this service if you have any previous Permanent make-up/tattooing on the Lip area** YOUR APPOINTMENT WILL BE CANCELLED and you will be charged $250 salon fee.

No-show for an appointment without rescheduling will result in a $250 fee charged to the card on file.

Touch-up 6-8 weeks after Initial Treatment - starts at $150 (Price subject to change.) Price includes 1 session.

Touch-up (within 1 year of first session) - starts at $250. (Price subject to change.) Price includes 1 session.

Touch-up (within 2 years of first session) - starts at $400. (Price subject to change.) Price includes 1 session.

Any visits after the initial and first touch up will incur a cost of $100+ (minimum).

Book your "touch up" after the allotted 10 week- Price is $150.

READ ME:

- We do not accept clients with previous PMU, Lip Blush, Cosmetic Tattooing, Etc on the treatment area.

- If you are over the age of 55 we must do an in person consultation before you may book an appointment. It is imperative that we access the skin to ensure you are a good candidate for permanent makeup.

-Failure to adhere to the above policies will result in your appointment being cancelled and you will be charged a fee of $100. No exceptions

I have read and understand the above policies.


How long does it last?

Everyone is different; it can last 1-3+ years. We suggest yearly touch-ups to maintain color and shape; however, some clients desire a touch-up every 6-12 months while other clients won’t return for a touch-up until year 2 or 3. Main factors in how long results last depend on age, skin type and sun exposure.

Does it hurt?

This is designed to be a gentle procedure with minimal discomfort. The degree of discomfort will depend on several factors, such as if you opt for anesthetics, location of the treatment, and your pain threshold. In the beginning you may feel a scratching feeling while we are marking the outline of the lips. A numbing cream is then applied which is absorbed into the bloodstream within a few seconds. Once the cream has absorbed, you will have relief from any disconfort. Lip tissue is very thin and sensative, it is normal for certian areas to be tender during the process.

Non-Candidates for PMU:

Have recieved Covid-10 Vaccine (need to wait 2 weeks before/after vaccine)

Over the age of 50 (results on mature skin cannot be guarenteed due to lack of collagen in the lip tissue, please schedule a consultation prior to booking to avoid cancellation fee)

Smoker of cigarettes (tar sits on lip tissue and will cause discoloration)

Pregnancy or nursing

Diabetic patients

Skin diseases

Directly after lip filler treatment (after 4 weeks is allowed)

Use of Accutane, Isoltretinoin, or other retinoids (after 6 months is allowed)

If you have a pacemaker, this manual method can be used, but any machine use is not allowed.

Very sensitive and pain intolerant

Sunburn or frostbitten (allowed after symptoms are gone)

Seborrhea Dermatitis

Very dry or peeling skin

Excessive sebum, oily skin

Problem skin broken capillaries

Acne

Moles

Keratosis

Very dry or peeling skin

Problem skin

ANY previous Lip work – Will need to schedule a consult!

Initial Consultation:

We provide free consultations if needed. The consultation will be approximately 20-30 minutes; this will not be your procedure day unless previously agreed upon.

If you require a Patch Test, it must be completed 48 hours before your treatment, or you can sign a waiver on the day of your treatment.

We take a photo of you so we can study the symmetry of your features. No one is exactly the same, and what we see as your ideal Lip shape might not be what you want, we want to achieve your perfect Lip. Our goal is to obtain symmetry and communicate realistic expectations. Please remember we can't make you look like your favorite celebrity or make your lips look magically two sizes bigger; we are artists not plastic surgeons. Miracle beautiful Lips that are true to YOU we can do. Be your own beautiful!

Before the Treatment:

**If any of these items occur, we will be forced to cancel your appointment and you will be charged a $250 fee**

DO NOT take Aspirin, Niacin, Vitamin E, Fish Oil or Ibuprofen 48 hours before.

DO NOT drink caffeine, alcohol or energy drinks on the day of treatment!! AND 1 day before treatment. ** This is EXTREMELY important *** These substances thin the blood, which will alter pigment color, cause discomfort/excessive bleeding and result in poor results.

If you get lip fillers, do it 4 weeks prior to treatment

Do not tan or sunbathe 1 week before treatment.

3-5 days before the procedure scrub your lips with a moisturizing lip scrub. Keep them moisturized to get the best result (use vaseline, coconut oil or your favorite chapstick).

Any and all Botox is recommended to be done 4 weeks prior to treatment.

No chemical peels, dermabrasion, mesotherapy or any other intense treatments. This will cause skin cells to rejuvenate faster which will result in skin irritation. We recommend any of these to be done 2-3 weeks before Lip blushing.

If you do not tell us you've had previous work on your Lips (ie... tattooing, surgical scars, injections, etc...) your appointment may be cancelled, and you will be charged a $250 fee.

On the Treatment Day:

Please arrive least 10 minutes before your appointment. Late arrival will NOT be accepted, please call us; it can lead to your treatment being postponed to another day. You will forfeit your deposit. If you are late on the day of your touch up, you will incur a $50 fee to rebook the touch up. We appreciate you contacting us when you are running late due to unforeseen circumstances, however, we run on a very tight schedule and cannot accept tardy clients.

At the start of your appointment we clean your Lip area with sterile, hygienic pads.

We will numb your lips so that you’ll feel less pain and discomfort.

We will go over your desired lip shape and tone, as well as any sketches that need your approval.

A photo will be taken, often times a photo will show defects or issues that may need to be addressed.

You will approve the lip shape before we start tattooing.

We use a disposable needles and tools for the procedure.

We use EU Regulated Permanent Makeup high quality pigments, specially manufactured for Lips.

Treatment Steps (procedure usually takes approximately 2 hours):

Consultation discussing treatment, shape and pigment color.

Numbing cream is applied to the skin; this takes approximately 20 minutes to take effect

Shape is drawn with a soft pencil.

Pigment is applied with a manual tool/and or machine using our technique.

Pigment is left to absorb and work its magic!

We clean the area.

Take a look at your new, gorgeous lips!

After the Treatment

Aftercare will be discussed.

When the lips are done, the immediate look after the procedure it's not the final color or end result. At first, the color will appear brighter and more vibrant, appearing more like a lipstick. Once your lips have healed, you can expect the color 50% lighter then they appeared immediately after the procedure. This will give you the beautiful natural color that you have always wanted! The final result will be a beautiful enhanced color of your natural lip color. The healing time is typically one week, however it does vary from client to client depending on your skin type - some clients need 10-14 days to heal.

Touch-up appointment will be scheduled 5-10 weeks from the date of initial treatment. *If touch-up appointment is not completed within 5-10 weeks from the initial lip treatment, a $50 fee will be required for the touch-up appointment.

I've read and understand the above information.

BROWFAIRY LLC (Taylor Steingold) Lip Blushing Aftercare Instructions

After care is very important in order to achieve a beautiful and lasting result.

Lips can swell up to 1 day. This is normal reaction.

Do not let your lips get dry. Use ointment given and apply thicker layer before bedtime.

Drink through a straw and avoid spicy and salty foods for several days.

No scrubbing. Do not rub, wipe, or scratch area. Use patting motions only.

Do not peel or pick at crust, this could cause pigment loss, scarring, and delayed healing.

Do not apply topical cosmetics over area while healing.

Do not have teeth bleached while healing.

Do not excessively stretch lips while they are healing with big smiles, or pucker lips with smoking.

During the peeling process it may look like there is not much color there. Color is more apparent by the second week. Final result is not judged for 1-2 months.

Failure to follow these instructions may result in pigment colour loss!

Touch-up visits should be scheduled between 6-8 weeks post procedure. Touch up is not included in the initial session cost and cost is $100.

For the service with any permanent make up procedure results may vary and everyone’s skin and bodies heal different there is no guarantee that it will be perfect after one session. It can take weeks to tell what the healed results will look like, with eyebrows and lips the color may disappear and come back. True color takes a full 4-6 weeks to be seen. Not everyone’s healing experience is the same and can not be compared. Please be patient and trust the procedure. Can’t wait to see you!


What's normal?

-Mild swelling, itching, light scabbing, light bruising and dry tightness. Aftercare balm is nice for scabbing and tightness. USE VASELINE DAILY ON LIPS

-Feeling too dark. After 2-7 days the darkness will fade and once swelling dissipates any feeling of unevenness usually disappears. If they are too dark or still a bit uneven after 5 weeks, then we will make adjustments during the touch up appointment.

-Color change or color loss. As the procedure area heals, the color will lighten and sometimes seem to disappear. This can all be addressed during the touch up appointment and is why the touch up is necessary. The procedure area has to be completely healed before we can address any concerns. This takes about five weeks.

Healing Process and Touch-Up:

Be sure to keep the lips hydrated during the first 7-14 days using vaseline. The full healing period is 28-45 days.

Be careful when washing your face, avoid hot water on the lips for 1 week.

If you have hyperpigmentation in the lips, note that Lip Blushing will NOT fully cover this. It will still likely be visible through the pigment. Hyperpigmented lip clients likely require more than 2 sessions to successfully neautralize the pigmentation of the lips. If you would like more than 2 sessions, a fee will be assessed. We do our best to neautralize the lips and color match but again, due to excessive pigmentation of the lips, the result will not always be ideal at first and will require more sessions.

Needing a touch up months or years later. A touch up may be needed 6 months to 2 years after the touch up procedure depending on your skin, medications and sun exposure. We recommend the touch up 6-8 weeks after the first session and every 6 months to 2 years to keep them looking fresh and beautiful. There will be a charge for any touch up sessions after 10 weeks. **Failure to follow after care instructions may result in infections, pigment loss or discoloration. Everyone's skin heals differently. It is important to remember that this is a two-part process and the second touch-up will complete the procedure. The touch-up is recommended between 6-8 weeks. Not everyone, but some people will need a touch-up to fill in areas that didn't take pigment, redeine the borders or achieve a more intensive color. After you have fully healed, you will see the finished result. Please be patient.

I have read, understand and agree to the above instructions.


Consent and Release Agreement for Microblading / PMU

This form is designed to give information needed to make an informed choice of whether or not to undergo a Lip Blushing Treatment. If you have questions, please don’t hesitate to ask. Although Lip Blusing is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

Lip Blushing is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are stickily adhered to. Artist is annually BBP Certified and Licensed.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.

Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7-10 days the color will fade 30-50%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years.

I have read, understand and agree to the above instructions.


Possible Risks, Hazards, or Complications

Pain: There can be discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than on others. Most of the time there is little discomfort!

Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See After Care sheet for instruction 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 so adjustments may be needed during the follow-up session to address any unevenness.

Excessive Swelling or Bruising: It is very common for lips to swell due to how sensitive the tissue is. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. It’s important to note that most people don’t bruise or swell more than 24 hours.

Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now.

MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a lowlevel magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI Technician of any tattoos or permanent cosmetics.

The alternative to these possibilities is to use traditional cosmetics and NOT undergo the SemiPermanent Lip procedure.

I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize Taylor Steingold, BROWFAIRY LLC, as my Lip Blushing technician to perform on my body the Lip Blush procedure desired today.


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 cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be 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 lip blush procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each individual’s reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent.


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

I have received pre- and post-procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood-altering prescription, I will advise my technician.

I understand that the taking of before and after photographs of the said procedure are a condition of such procedure. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and the procedure process. I accept full responsibility for the decision to have this cosmetic tattoo work done.

Treatment: Lip Blush, Lip Blushing / PMU Statement of Consent and Recitals: Please read and initial

Aftercare instructions have been explained to me and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email you.

I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.

I understand that RetinA, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.

I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup.

I understand that successful color saturation can NOT be guaranteed.

I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue from a previous tattoo or scar.

I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.

I accept the responsibility to explain to you my desire for specific colors, shape, and position for any procedure done today.

I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 60 days.

I acknowledge that the proposed procedures(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.

I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Touch-ups must be completed within 60 days of initial procedure.

I understand that it is my responsibility to book my touch up appointment in the allotted time frame (6-8 weeks) following my first treatment or else I will be charged a fee for the touch up. It is my responsibility to book in advance since Taylor Steingold, BROWFAIRY LLC, books up quickly and I will be charged if my touch up is 10+ weeks post first session due to trying to book last minute.

I have been quoted the cost of today’s appointment, and the cost of the touch-up. Touch-ups must be completed within 60 days of initial procedure or an additional cost may apply.

All information gathered from the client that is personal medical information and that is subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or similar state laws shall be maintained or disposed of in compliance with those provisions.

I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have a tattoo at this time.

I understand I will have permanent make-up applied using appropriate instruments and sterilization techniques. I understand that the permanent make-up site usually takes 2 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors, and the management of the permanent make-up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure.

I am aware that tattoo inks, dyes, and pigments have not been approved the federal Food and Drug Administration and that the health consequences of using these products are unknown.

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my blood.

If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my tattoo.

I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the permanent make-up, or any open wounds or lesions at the site of the tattoo. I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.

I have advised the Technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reaction to the permanent make-up process and further acknowledge that such reaction is possible.

I have read and understand ALL of the statements above.

I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize BROWFAIRY LLC, Taylor Steingold, as my lip blush/blushing technician to perform on my body the Lip Blush Tattooing procedure desired today.


Today's Date: June 30, 2025


First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
Yes
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
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*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Photography Release Consent- *We would like your permission to use these photos for advertising or marketing purposes. Your name will not be used and/or affiliated with the photos posted. Your consent is necessary regarding this. Please indicate that you understand your before and after procedure photos may be used for advertising/marketing purposes online and otherwise.**
No
Yes
Have you received the COVID-19 vaccine within the last 2 weeks? Note: Appointment must be scheduled 2 weeks after/before 2 weeks of receiving the vaccine.**
No
Yes
Are you prone to or have you ever had the HERPES VIRUS, COLD CORES/fever blisters, chicken pox or shingles? This procedure can activate the virus responsible for the eruption and cause an outbreak. Please mark YES if you have experienced any of the above, and contact me immediately for proper preparation BEFORE appointment.**
No
Yes

Client Medical History Form, please complete the following questions:

Diabetes ----(Lip Blushing causes small shallow wounds on the skin, the healing of which will be complicated if your blood sugar is high. People with uncontrolled diabetes have poor wound healing because there is less oxygen supply to the tissues and fewer blood vessels. Aside from this, elevated blood sugar makes you prone to infection, because it lowers your immune system. - Please consult your doctor prior to booking)**
No
Yes
Are you Anemic / Do you have low iron levels? --- Due to elements present in permanent make-up pigments, individuals that have low levels of iron will physically not retain pigment.**
No
Yes
Pregnant now --- If Yes, you will need to wait to make an appointment until after pregnancy is complete and/or breastfeeding has come to an end.**
No
Yes
Chemotherapy/ Radiation --- Must wait 6 months AFTER treatment**
No
Yes
Hepatitis A B C D* *
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc --- Must stop use of the above medications one week prior to Lip Blush.**
No
Yes
Autoimmune disorder**
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc**
No
Yes

Any diseases or disorders not listed, Please list above

Please list any medications you are taking:

*NOTE* - Please send clear photos of Lips with no make-up in natural lighting to BROWFAIRYPMU@gmail.com or 858-221-2346

Have you had previous work done to your Lips? (ie. tattooing, prior lip blush, etc...)**
No
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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