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THE LUSH STUDIO - MICROBLADING INFORMED CONSENT, MEDICAL HISTORY & RELEASE FORM Please read and fill out this form completely, making certain that you fully understand everything and print your contact information clearly Name: DOB: Address: Phone Number: Email: Emergency Contact: How did you hear about The Lush Studio? Microblading is a (semi) permanent cosmetic procedure that is done using a manual tool. Each hair stroke implants pigment into the upper layers of the skin, resulting in semi permanent brows lasting anywhere between 12-24 months. Some redness, swelling, slight bruising, and itching may occur post-procedure, this is normal. The healing and scabbing cycle takes about 14 days to complete and finished results are after 4 weeks. Please refer to the information handouts for complete after-care instructions. You have the right to be informed so that you may make the decision whether or not to undergo the procedure(s) after knowing the risks and hazards involved. This disclosure is not meant to frighten you, it is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure. Please read the statement below and initial before each one to indicate you understand them completely. As a client, it is your responsibility to inform the technician of all possible concerns before they begin your procedure. I am at least 18 years of age and have presented my ID as proof. I am not under the influence of alcohol or drugs or any other substances, legal or otherwise. I have been informed that I will receive a free touch up within 4 to 6 weeks after the procedure and if I fail to come back within that time frame I will have to pay for my touch up. I understand that The Lush Studio has a 24-hour cancellation policy and I must cancel or reschedule at least 24 hours prior to my appointment. I understand that it is my responsibility to inform my technician of any problems that I (or my physician) think could occur for any reason including but not limited to: allergies and illnesses and any medications I am taking including aspirin and/or other medications that cause the blood to thin. I understand that The Lush Studio may elect to delay or not go forward with the procedure based on this information. I understand that I am responsible for the cost of any touch ups after my free 4-6 week touch up.