Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Procedure/Service
Ombre Brows
Lip Blushing
Scar Camouflage
freckles
Other
Are you currently taking any medications?
Yes
No
What are the medications you're currently taking and what is their purpose?
If any please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Are you wearing contact lenses?
Yes
No
Do you have any implants?
Yes
No
Do you have any Botox or other injectables?
Yes
No
Do you participate in outdoor recreational activities?
Yes
No
Please check below if you have the following medical condition:
Rows
Yes
No
Remarks
Cancer
Hyperpigmentation
Keloid
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Cancer
Venereal Disease
Asthma
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia
Have you had micropigmentation before?
Yes
No
When did you have it?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Beauty Clinic
Acknowledgment
Type a question
I understand that this procedure cannot guarantee 100% expected results.
I allow Lshablenyc to take photographs for case review which is before and after.
I allow Lashablenyc o use this photograph for a marketing campaign or advertising.
I release lashablenyc for any liabilities related to the treatment and result specifically allergic reactions and applied pigmentation.
I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.
I understand that permanent cosmetics are a form of tattooing.
I confirm that a healing period is required before the next or before the touch-up treatment.
I understand that this procedure might be painful and requires patience.
I understand that there might be an allergic reaction even though we do a skin test 24 hours before.
I understand that I might experience infection, minor bleeding, swelling, and redness.
I confirm that I have read, understand, and answered this consultation form accurately to the best of my knowledge.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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