Trophy Beauty By Destiny Renee
9108 Laguna Main st suite 5 Elk Grove CA 95758
Microblading Intake Form
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
How were you referred?
Microblading is a tattooing technique in which a small hand held tool is used to add pigment into the skin. A touchup session is recomended 4 to 6 weeks after application in order to maintain the effect. Signs of symptoms of allergic reaction: Swelling that extends into the eyelids or other places on the face, Redness that extends beyond the eyebrow and up into the scalp or cheek area, Warmth when touching the red areas, Tenderness and/or pain to your face/eyebrows, Fever or chills or increase in sweating (signs that suggest you have a systemic infection), Drainage or foul discharge from the procedure site. Sign below that you understand to procedure to be performed:
Have you previously had eyebrow permanent makeup? If so, upload image below.
Permanent Makeup Consent
I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from Trophy Beauty By Destiny Renee. I acknowledge that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows:
I acknowledge that the following information Is true.
_______I am not under the influence of alcohol or drugs._______I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing excluded). _______I have looked over my design and give my full consent to the application of my tattoo. _______I acknowledge that I am not pregnant._______I acknowledge that I am free of communicable disease. _______I acknowledge that I have truthfully represented to the associates, agents and representatives of Trophy Beauty By Destiny Renee that I am over eighteen (18) years of age. _______I acknowledge it is not reasonably possible for the associates, agents and representatives of Trophy Beauty By Destiny Renee to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and I agree to accept that such risks are possible. _______I acknowledge that infection is always possible as a result of obtaining a tattoo particularly in that event that I do not take proper care of my tattoo, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. _______I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about the body art procedure have been answered to my satisfaction. _______I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. _______I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove my tattoo. _______I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or conduct of the associates, agents or representatives of Trophy Beauty By Destiny Renee that are reasonable necessary to perform the tattoo procedure. ______I agree to release and forever discharge and forever hold harmless Trophy Beauty By Destiny Renee and its associates, agents officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by Destiny Renee and its associates, agents and representatives in the future. ______I acknowledge that tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown. ______I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. ______I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense. ______ I authorize my technician to take photographs of the work performed both before and after the treatment and I authorize the use of the photographs to be used for advertising.
I have been fully informed of the risks of tattooing including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, and latex gloves. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing.
Please answer yes or no to all conditions listed below that apply to you
HEMOPHILIA /OTHER BLEEDING DISORDER
PREGNANT / NURSING
FAINTING OR DIZZINESS
SCARRING OR KELOIDING
GONORRHEA / SYPHILIS
MRSA/ STAPH INFECTION
How long has it been since you ate?
Do you have any additional allergies such as metals, latex, soaps, cosmetics or alcohol? If so explain:
Do you use any medications that might affect the healing of the body art you wish to receive? If so explain:
Keep area clean, but do not wash brows with soap for 7 days. You may carefully cleanse around the brows or eyelids. Do not rub skin vigorously when washing your face for at least 10 days. Do not apply makeup to the tattooed area for at least 3 - 5 days. Occasionally people will experience swelling or redness. Understand that your eyebrow color will appear dark for approximately 4 to 5 days. Do not try to remove the excess color with soap. The color will flake and fade to a beautiful, natural color if left undisturbed. Do not sun bathe without the use of sunglasses for 30 Days. Do not swim in pools or hot tubs for 7-10 days. After approximately 3 days, you may feel itching. This does not mean you are allergic to the pigment, but the flaking process has started to take place. Gently apply ointment morning and night for 5 days. Signs and symptoms of infection include, but not limited to, severe redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site. Discharge from site may be green/yellow in color and foul in odor. SEEK MEDICAL CARE IF ANY SIGNS OR SYMPTOMS OF INFECTION DEVELOP. Sign below that you understand:
Should be Empty: