BEAUTY KULTURE STUDIO & ACADEMY MICROBLADING PERMANENT MAKEUP FORM

BEAUTY KULTURE STUDIO & ACADEMY

MICROBLADING & PMU CONSENT FORM
Name*

First NameLast Name
Email*
example@example.com
Referred by:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date*

MonthDayYear
Date
Time*

:HourMinutesAM/PM Option
List any medications you have been taking in the past 6 months:*
Have you received chemotherapy or radiation in the past year?*

YesNo
Have you ever had an allergic reaction to any of the following :

LatexLanolineVaselineMedicationMetalsLidocaine ProductsCrayons GlycerinMetallic SaltsHaircolorFoods
Are you currently taking Blood thinner medication ?*

YesNo
Do you have active cold sores ? IF YES PLEASE CONTACT YOUR PHYSICIAN FOR A PREVENTATIVE PRESCRIPTION*

YesNo
Are you currently under the care of a physician?*

YesNo
If you ARE UNDER DOCTOR'S CARE, please explain:
Do you take antibiotics when going to the dentist?*

YesNo
If you DO TAKE ANTIBIOTICS when going to the dentist, please explain:
Have you ever had one of the following:

Alopecia (Hair Loss)AnemiaDiabetesSensitivity to cosmeticsProlonged BleedingTrichotillomaniaEpilepsyPacemaker (Artificial Heart Valve)Low Blood PressureHigh Blood PressureHemophiliaHIV/AIDSFainting Spells/DizzinessCirculatory ProblemsKeloid Skin/Skin HypertrophiesLiver DiseaseTumorsAny Abnormal Skin GrowthsCystsBotox/FillersHepatitisThyroid ConditionsCancerHealing ProblemsScarring of the Skin (Easily)Easily Bleed/Bruise
What would you like to improve about your eyebrows/eyes/lips/hairline/scalp/areola? Consider shape, color, density, thickness, fullness, etc…*
Please only describe the areas that brought you in for a visit.
Please read the following statements carefully.

Microblading and other permanent cosmetics is a way of cosmetic tattooing, intended to be semi permanent lasting average 12-18 months. On a rare occasion, the pigment may migrate under the skin. Procedure of microblading and other permanent cosmetics may be uncomfortable. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be performed if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after microblading procedure, you should notify/discuss with your doctor. Possible scarring may occur.
PLEASE READ THE FOLLOWING NOTICE:
You are hereby notified of the possible risks and dangers associated with the application of each tattoo. These risk and dangers include, but are not limited to, at least the following:
I. the possibility of discomfort or pain;
II. the permanence of the markings;
III. the risk of infection; and
IV. the possibility of allergic reaction to the pigments or other materials used.
NO PERSON MAY BE TATTOOED WHO APPEARS TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS.
Signature*

Clear
Should be Empty: