NEW CLIENT | NEW PROCEDURE - Permanent Make-Up & Microblading Consent Form

TO BE FILLED OUT BY NEW CLIENTS ONLY

PERMANENT MAKE-UP & MICROBLADING CONSENT FORM
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Must type in age due to state regulations
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How would you like your permanent make-up to improve the appearance of your brows and/or lips?
Upload a front-facing, make-up free photo in daylight of your brows and/or lips (this step is required for those who have had previous permanent make-up or whom I have not seen previously).

Cancelof

	Yes	No	Remarks
Cancer
Hyperpigmentation
Keloids
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Venereal Disease
Asthma
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia

TO BE FILLED OUT BY NEW CLIENTS ONLY