Medical History & Consent

Medical History & Consent Form

Permanent Makeup
Name*

First NameLast Name
Gender*
Are you 18 or older?*

YesNo
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about us?

FacebookInstagramGoogleYelpOther
Medical History
Have you ever had permanent cosmetics done in the past? If yes please list which type and how long ago. (Example: Microblading, 3 years ago / Eyebrow Tattoo, 10 years ago)*
Skin Type*

DryOilyCombinationNormal
Have you ever had an allergic reaction to the following:*

AntibioticsLidocaineEpinephrineLatexMetalsPermanent MarkersCosmeticsLavenderBeeswaxNone (free of allergies)Other
Do you have any of the following conditions?*

Eye disordersProne to eye infectionsAutoimmune disordersHyperactive thyroid or Graves DiseaseHeart issuesRashesDiabetesMitral Valve ProlapseCardiac valve diseaseAlopeciaTrichotillomania (hair pulling disorder)Hemophilia or another bleeding disorderBleeding or bruising easilyHistory of keloids (raised scarring)History of herpes / cold sores or fever blisters on proposed procedure siteEpilepsy, narcolepsy or fainting spellsHistory of skin disease or skin sensitivityHistory of nerve damage on the area to be treatedNone (free of medical issues)Other
Do you wear contact lenses?*

YesNo
Are you pregnant or nursing? (If yes, you must wait until after the baby is delivered to receive permanent cosmetics)*

Yes, I’m currently pregnant.Yes, I’m currently nursing.No
Have you ever had any of the following:*

HIVHepatitis AHepatitis BHepatitis CNone
Prior to dental procedures, do you receive antibiotic therapy?*

YesNo
When you go to the dentist and receive anesthetic, do you require extra numbing during the procedure?*

Yes, the numbing wears off quickly on me.No, I’m usually pretty numb throughout the whole procedure.I’m not sure.
Have you had botox in your forehead within 2 weeks of the appointment date?*
Are you taking any steroids or anti-inflammatory medications?*

YesNo
Are you currently taking any other medications? If yes, please list them below:
Technicians make no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent make-up applications. These complications are usually mild and last only a few days. However, complications are always a possibility. If you are healthy and there are no visible reasons for restricting you from receiving a tattoo, you must approve of the procedure and the shape/color before the application of your permanent cosmetics. All provided medical information is confidential.
Touch Up Fee Schedule

Subject to change.
6-12 week follow up - $175

1 year - $250

2 years - $400

Strokes / color must still be visible. After 4 years it will automatically be considered a new procedure.

The amount of time needed between touch ups varies from person to person.

**Please note we have a no refund policy.**
Authorization
- I confirm that all information given in this form is true, complete, and accurate.
- I confirm that I am over the age of 18 and not under the influence of drugs or alcohol at the time of my procedure.
- I understand that I must inform my technician of any and all medication(s) I am currently taking. (Pain control medications such as aspirin or ibuprofen may cause the blood to thin, and excessive bleeding may occur during or after the procedure.)
- I give my consent to confer with my physicians for medical information required for the safety of my procedures.
- I understand that with time the pigment will fade and can change according to metabolism, skin type and tone, medication, age, sun exposure, Retin-A and Glycolic acids. I understand that fading and color changes are what determines that it is time for a touch up.
- I understand that everyone’s skin heals differently. No warranty has been made to me as a result of this permanent makeup, micro-pigmentation, removal or correction procedure. I understand and accept that such procedure is a process requiring a follow up application of color to achieve desirable results and that 100% success cannot be guaranteed. I understand that this is why I need to return for a follow up appointment within 3 months which is priced separately. I understand that I will need to come in yearly for a touch up and that some may need to come in after 6 months.
- If I have had permanent cosmetics performed previously by another technician I will not hold Morgan Finley responsible for future allergic reactions or contraindications. I also understand that these cases may take more appointments to create desired results. Correction work can never be guaranteed.
- I understand that it is my responsibility to advise the technician of any concerns I may have before they begin the procedure.
- Cosmetic tattooing is considered permanent, but will fade with time. I understand the permanent nature of cosmetic tattooing and the fact they can only be removed with surgical or laser procedures, and that any effective removal may leave permanent scarring or disfigurement. Misplacement or migration of the pigment can occur under rare circumstances, requiring excision and/or correction of the misplaced pigment.
- I understand that inks, dyes and pigments used in tattoing and permanent cosmetics have not been approved by the FDA and that the health consequences of using these products are unknown. I understand there is a possibility of discomfort, bleeding, swelling, and allergic reactions to the pigments used.
- I release Morgan Finley, representatives and subsidiaries of all claims for injury, seen or unseen, that may occur as a result of this procedure.
- I have received a copy of my aftercare instructions and agree to follow them to my best ability. I understand that there may be risk of infection or pigment loss if aftercare instructions are not followed completely. Aftercare instructions can always be accessed on facesbymorgan.com in the "forms" section.
- I understand that taking before and after pictures is required and I give consent for them to be used for marketing/promotions. (Most photos are of the procedure area only and do not show the entire face. If you would not like your photos to be used, please let us know.)
- I fully understand the questions, terms, and conditions of this Disclosure & Release Agreement. I accept to waive my rights for any claim against my technician for any reason.
- I certify that this Disclosure & Release Agreement was completed by me and that all entries and information are true and complete to the best of my knowledge.
I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Client Signature*

Clear
Date*

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Date
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Medical History & Consent Form

Medical History

Touch Up Fee Schedule

Authorization