Microblading Intake Form
General Information
Full Name
*
Email
*
example@example.com
Phone
*
Medical History
Please check all that apply
Acne
Arthritis
Depression
Diabetes
Eczema
Epilepsy
Fever Blisters
Heart Condition
Hepatitis
High Blood Pressure
HIV
Hyper Pigmentation
Hypo Pigmentation
Insomnia
Low Blood Pressure
Lupus
Sinus Infection
Pregnant
Currently Breast Feeding
Psoriasis
Rashes
Seborrhea
Shingles
Skin Cancer
Hyper/Hypo Thyroid
Warts
Surgery (Please explain in "Other" field)
Other
Are you currently taking any medications?
Yes
No
If yes, please explain
Have you had any facial or dermatology services in the past 30 days?
Yes
No
If yes, please explain
Do you have any allergies?
Yes
No
If yes, please explain
By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.
Name Printed
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Signature
*
Date
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Month
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Day
Year
Date
Client Consent Form & Liability Waiver
I hereby consent to and authorize Beautiful Browns & Esthetics/Brookelyn Foster to perform the following procedure:
Enter requested procedure here
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me. I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is a possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment of suggested home product/post-treatment care, I will consult the esthetician immediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
Printed Name
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Full Name, please
Signature
*
Date
*
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Month
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Day
Year
Submit
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