Visage Ink and Beauty
Client Medical History Form
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Medical Conditions:
Diabetes
High blood pressure
Heart condition
Autoimmune disorder
Thyroid disorder
Skin conditions
Keloid scarring
Epilepsy/seizures
Cancer
Pregnant or nursing
Medications:
Current Use:
Accutane (past 12 months)
Retin-A /Retinol
Blood thinners
Steroids
Latex
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Lidocaine
Pigments
Other allergies:
Previous permanent makeup:
Yes
No
Details:
Signature:
Date:
-
Month
-
Day
Year
Date
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Visage Ink and Beauty
Informed Consent & Liability Waiver
I understand permanent makeup is a tattoo procedure with risks including infection, allergic reaction, and dissatisfaction with results.
I acknowledge results vary, may require touch-ups, and pigment may fade.
Client Name:
Signature:
Date:
-
Month
-
Day
Year
Date
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Visage Ink and Beauty
Photo Release Consent
I authorize use of my photos for:
Social Media
Website
Marketing
Consent:
I consent
I do NOT consent
Signature:
Date:
-
Month
-
Day
Year
Date
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Visage Ink and Beauty
Procedure Consent
Procedure Type:
Microblading
Ombre/Powder Brows
Lip Blush
Eyeliner
I understand the procedure, healing process, and multiple sessions may be required.
Signature:
Date:
-
Month
-
Day
Year
Date
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Visage Ink and Beauty
Aftercare Acknowledgment
I understand and agree to follow all aftercare instructions provided.
Signature:
Date:
-
Month
-
Day
Year
Date
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Visage Ink and Beauty
Touch-Up Agreement
Touch-ups are typically required 6-8 weeks after the initial session.
Policy:
Policy
Included
Not Included
Must be scheduled within (weeks):
Signature:
Date:
-
Month
-
Day
Year
Date
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Visage Ink and Beauty
Cancellation & No-Show Policy
Deposit amount:
Required notice (hours):
I understand missed appointments or late cancellations may result in loss of deposit.
Signature:
Date:
-
Month
-
Day
Year
Date
Preview PDF
Submit
Submit
Should be Empty: