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Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency contact name and number:
Which skin issues are most concerned about? Check all that apply

Bumpy skin Cysts/Nodules Dull skin Blackheads Acne Acne Scars Age spots Facial veins Wrinkles Large pores Melasma Redness Sun damage
How would you describe your skin?

Dry Oily Combination Sensitive
Select current skincare products

Cleanser Moisturizer Serum Exfoliater Sunscreen Retinol Glycolic acid
The following conditions are recognized as contraindications of BB Glow and must be disclosed and discussed with esthetician prior treatment. Please check all that apply.

Liver disease Pregnancy Accutane treatment (within 1 year of treatment) Diabetes type 1 and 2 I confirm I have none of these medical conditions.
Are you currently taking any medications?

Yes No
Please list.
Do you have allergies

Yes No
Please list
Do you tan or use tanning booths?

Yes No
Do you receive laser treatment or chemical peels?

Yes No
Please check each box to acknowledge your understanding and agreement to the BB Glow treatment

I’m over the age of 18 I am not under the influence of any drugs or alcohol I want to receive a semi permanent pigmentation procedure I am not pregnant or breastfeeding The general nature of cosmetic micropigmentation as well as the specific procedure to be performed has been explained to me. If an unforeseen condition arises in the course of the procedure I authorize my therapist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 4-6 months. I have been informed that the highest standards of hygiene are met and that sterile disposable needles and pigment containers are used for each individual client procedure and visit. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I have to return for a repeated procedure after 2 weeks for the results to last 4-6 months. The result of the procedure can be affected by the following: medication, skin characteristics (dry oily sun-damaged thick or thin skin type) personal pH balance of your skin alcohol intake and smoking post procedure after care. Sunscreen is highly recommended on a daily basis I understand that some skin types accept pigment more readily and some skin types can need more than 1 session to achieve the desired look. 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 scarring inconsistent color and spreading fanning or fading of pigments. Normal activities can be continued following the procedure however using cosmetics, excessive perspiration and exposure to the sun until the skin has fully healed. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may lower my chances for a successful procedure. I accept the responsibility for determining the desired look and the PMU procedure as agreed during consultation. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done. We have your consent to take your photos for education purposes and post them online on my social media. I give The Beaut Clinic permission to perform my BB Glow procedure. By my signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.
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