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Client History, Consent, and Disclosure Agreement
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1
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3
33%
Name
First
Last
Email
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
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Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
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Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
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South Sudan
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Sudan
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Switzerland
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Taiwan
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Virgin Islands, U.S.
Wallis and Futuna
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Zimbabwe
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Country
Phone
PROCEDURES DESIRED:
Microblading
If other please explain.
Have you ever had a cold sore?
Yes
No
If yes, you must contact your physician for a prescription of ZOVIRAX capsules, an antibiotic that prevents cold sores.
I have read the above information regarding ZOVIRAX and understand its use is mandatory if I desire lipline or full lip color procedures
Signature
First
Last
Who referred you?
Are you currently under the care of a physician?
Yes
No
If so, why?
Physician's name:
Do you take antibiotics when going to the dentist?
Yes
No
If yes, why?
Do you suffer from:
Allergies
Moles or freckles at site of tattoo
Hepatitis
Heart Problems
Hemophilia
Diabetes
Skin Problems
Scarring (Keloids) Eye
Problems
Epilepsy
None of the above
If other please explain.
Are you presently taking medication that thins blood?
Yes
No
Are you taking other medications?
Yes
No
If yes, explain.
Are you pregnant or nursing?
Yes
No
Do you wear contact lenses?
Yes
No
I understand that if I fail to cancel before 72 hours of my appointment I will forfeit my 50% deposit of the full cost of the procedure(s).
Sign
First
Last
Date
MM slash DD slash YYYY
I am over the age of 18, am not under the influence of drugs or alcohol, and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.*
Product Name
Procedure(s)
Microblading - 2 visits required
Procedure(s)
Lip Lining
Total Cost of Procedure(s)
$0.00
I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s).
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.
I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.
I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s). I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.
Sign
First
Last
Date
MM slash DD slash YYYY
Please read and fill out this “Disclosure & Release Agreement” completely, making certain that you understand all information provided, and that your information is correct. You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure. Please read and INITIAL the statements below to indicate that you understand the information completely:
*
No food, drinks, or making/receiving phone calls are allowed in the procedure area. Minimal texting or email is totally fine, as long as it does not interfere with the procedure. (This applies to any guests of the client as well.)
*
No warranty has been made to me as a result of this semi-permanent make-up/Microblading or correction procedure, and that the final result cannot be guaranteed.
*
There may be risk of infection if aftercare instructions are not followed.
*
I realize that there is potential for discomfort during the procedure and during the healing process.
*
There is a possibility of bleeding, swelling, and allergic reactions to the pigments used.
*
Cosmetic tattooing is considered semi-permanent, and may fade with time.
*
A tattoo can only be removed with surgical or laser procedures, and any effective removal may leave permanent scarring or disfigurement.
*
Misplacement or migration of the pigment can occur, under rare circumstances, requiring excision and/or correction of the misplaced pigment.
*
I have reviewed the ABOUT MICROBLADING & Microblading Policies sections on www.Heidi Christines.com prior to my appointment, I understand the info there, and have had any further questions answered.
*
My technician will not, under any circumstance, perform any procedures on me if I am known to have any allergies related to the products used. (Our pigments contain: Sterile Water, Glycerin, Isopropyl Alcohol, Iron Oxides, Titanium Dioxide, and Chromium Oxide)
*
I understand that I must inform my technician of any and all medication(s) I am currently taking. (Pain control medications such as aspirin or ibuprofen may cause the blood to thin, and excessive bleeding may occur during or after the procedure.)
*
I do not currently take Accutane and/or have not taken for at least 12 months.
*
I understand that I must inform my technician of any skin condition(s) I may have. (Psoriasis, Eczema, etc.)
*
I understand that it is my responsibility to advise the technician of any concerns I may have before they begin the procedure.
*
I am not under the influence of any drugs or alcohol.
*
I am not pregnant.
*
I am actually reading these and not just checking the boxes.
*
After-Care instructions have been explained to me and a written copy has been given to me, which I will follow to the best of my ability.
*
I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.
*
I release the salon and its representatives and subsidiaries of all claims for injury, seen or unseen that may occur as a result of this procedure.
*
I fully understand the questions, terms, and conditions of this Disclosure & Release Agreement. I accept to waive my rights for any claim against the technician for any reason whatsoever.
Consent
*
I believe that I have sufficient information to give this informed consent.
*
I certify that this Disclosure & Release Agreement was completed by me and that all entries and information are true and complete to the best of my knowledge.
Please Choose
*
YES, I would like to give my consent for my before/after photos to be shown on social media (Instagram/Facebook/Twitter/etc.) and in printed materials. (Your face will not be shown and you will not be tagged in the photo. Just a photo of the work that was done.)
NO, I would NOT like to give my consent for my before/after photos to be shown on social media (Instagram/Facebook/Twitter/etc.) and in printed materials. (Your face will not be shown and you will not be tagged in the photo. Just a photo of the work that was done.)
Consent to Charge Credit Card
I authorize Heidi Christine’s to charge my credit card for 50% of the total amount as my deposit. I understand that if I fail to cancel my appointment before 72-hours of my appointment I will forfeit my 50% deposit.
Credit Card Number
*
Expiration Date
*
CIV
*
Sign
*
First
Last
Date
*
MM slash DD slash YYYY
Δ
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