Microblading/ Powder Brows

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Drivers License STATE and NUMBER*

Emergency Contact Information

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Relationship to you*

Medical History

Are you pregnant:*

YesNo

Do you have a heart condition, epilepsy, or a diabetic?*

YesNo

If yes, Please explain:

Are you hemophiliac or on any medications that may cause bleeding or may hinder blood clotting?*

YesNo

If yes, Please explain:

Do you have any communicable diseases? (H.I.V., A.I.D.S., HEPATITIS)*

YesNo

Are you under the influence of alcohol or drugs, prescribed or otherwise?*

YesNo

Do you have any allergies? (Medicines or topical solutions)*

YesNo

Have you had any alcohol, caffine or OTC pain relievers in the last 24 hours?

YesNo

Waiver and Release

Initial Each Point:

Failure to complete will result in cancellation of your appointment

To my knowledge, I do not have any mental or medical impairment or disability which might affect my well being as a direct result of my decision to have any semi-permanent tattoo procedure done at this time.*

Initial

I agree to follow all instructions concerning the care of my semi-permanent tattoo while it’s healing. I agree that any touch up work, due to my negligence, will be done at my own expense.*

Initial

I understand that if my skin color is dark, the colors will not appear as bright as they do on lighter skin. *

Initial

Being of sound mind and body, I hereby release all employees, agents or persons representing Ashley Lynn Esthetics from all responsibility. I agree not to sue Ashley Lynn Esthetics its heirs or allocates in connection with all damages, claims, demands, rights, and caused by any negligence of Ashley Lynn Esthetics and its employees.*

Initial

I understand that in rare cases a 3rd appointment may be necessary and the cost is not included in the original pricing. I understand that if a 3rd appointment is needed there will be a fee.*

Initial

I agree for myself, my heirs, assigns and legal representatives to hold harmless from all damages, actions, causes of action,claim judgments, cost of litigation's, attorney’s fees and all other costs and expenses which might arise from my decision to have any semi-permanent tattoo work done by Ashley Lynn Esthetics and its employees.*

Initial

I have been advised that the tattoo will be Semi-permanent and that it can only be removed with surgical procedure, and that any effective removal will leave permanent scarring and disfigurement. This cautionary notice is required to be provided to me by the health department of New York State and I hereby acknowledge receipt of this formal notice.*

Initial

I agree to pay for all damages and injuries to any persons or property belonging to Ashley Lynn Esthetics or any other person to whom they may become liable contractually or by operation of law, caused by or resulting from my decision to have any semi-permanent tattoo work done by Ashley Lynn Esthetics.*

Initial

I hereby grant irrevocable consent to and authorize the use of any reproduction by Ashley Lynn Esthetics, all photographs which are taken this day of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video or live internet stream shall become and remain the property of Ashley Lynn Esthetics, solely and completely. *

Initial

To complete the look of the eyebrows, a touchup/perfection appointment is required 30 days after initial appointment, NO LATER THAN 5 WEEKS. I understand if I cannot make it back before that a fee will be imposed.*

Initial

I swear or affirm and agree that the above information is true and correct. I have been provided with information describing the semi-permanent tattoo to be performed and instructions on aftercare. I have been made aware that if I have any signs or symptoms of infection, such as swelling, pain, redness, warmth, fever, unusual discharge or odor to contact my physician. It is also my responsibility to take care of my new semi-permanent tattoo according to the instructions provided both verbally and in writing. *

Initial

I UNDERSTAND THAT THERE IS NO WARRANTY OR GUARANTEE MADE TO ME AS A RESULT OF THIS PROCEDURE AND THE FINAL RESULT CANNOT BE GUARANTEED. I UNDERSTAND THERE IS NO REFUNDS FOR THIS PROCEDURE ONCE SERVICES ARE RENDERED. RESULTS WILL VARY, AND INDIVIDUAL RESULTS ARE NOT GUARANTEED OR TO BE MADE PREDICTABLE, AS THERE ARE MANY VARIABLES THAT CONTRIBUTE TO THE FINAL RESULT, SUCH AS AFTERCARE, SKIN TYPE, LIFESTYLE, ETC. I understand, read and completed the questionnaire truthfully. I understand that withholding ANY information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand that this waiver replaces any verbal or written disclosures. The treatments I receive here are voluntary, and I release Ashley Lynn Esthetics and/or esthetician from any liability, and I assure full responsibility thereof. I hereby grant irrevocable consent to and authorize the use of any reproduction by Ashley Lynn Esthetics, all photographs which are taken of me, negative or positive proof which will be hereby attached for any purposes whatsoever, without further compensation to me. All negatives, together with the prints, video or live internet stream shall become and remain the property of Ashley Lynn Esthetics, solely and completely. I understand and release Ashley Spina from any liability if I should fall or hurt myself in any way on her property located at 641 Union Rd. I understand that Ashley Spina is not responsible for lost, stolen or damaged items including my vehicle that is parked on the property.*

Date*

Date

Please upload your valid drivers license*

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