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THE LUSH STUDIO - MICROBLADING <br /> INFORMED CONSENT, MEDICAL HISTORY & RELEASE FORM <br /> I understand there may be risks and hazards related to the performance of this procedure, <br /> including but not limited to: allergic reaction to the pigment and/or other products that will be used, <br /> light headedness, bleeding, bruising, swelling, scarring and infection. <br /> I understand that pigments are not FDA approved and health consequences are unknown. <br /> No warranty or guarantee has been made to me as a result of this procedure, and although <br /> my technician will do their best to make sure I am happy with the result, the final result cannot be <br /> guaranteed. Microblading is semi-permanent, so it is recommended to get touch ups after it fades <br /> over time. <br /> I understand that I need to follow the aftercare procedure to insure proper healing results. <br /> I fully understand the questions, terms, and conditions of this Informed Consent, Medical <br /> History and Release Agreement, and all questions have been answered for me. <br /> CONFIDENTIAL MEDICAL HISTORY <br /> Are you pregnant? No Yes <br /> When was your last meal? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> No Yes <br /> Have you had Botox/Dysport or any fillers in the last two weeks? No Yes <br /> Are you currently using, or have you used any products containing Retin-A or Hyaluronic Acid (or <br /> similar ingredient)? No Yes <br /> Do you use any medications that might affect the healing of the procedure you wish to receive? <br /> No Yes If yes, list all here: <br /> Please list ALL medications you are taking: <br /> Are you allergic to Latex? No Yes <br /> List ALL other allergies here (including Antibiotics): <br />