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THE LUSH STUDIO - MICROBLADING <br /> INFORMED CONSENT, MEDICAL HISTORY & RELEASE FORM <br /> I, certify that this Informed Consent, <br /> Medical History and Release Agreement was completed by me and that all entries in it are true and <br /> completed to the best of my knowledge. I also certify that I have been fully informed of the risks of <br /> Microblading, including but not limited to: infection, scarring, and allergic reactions to pigment, latex <br /> gloves, and other products used. Having been informed of the potential risks associated with <br /> Microblading, I still wish to proceed with the application and I assume any and all risks that may arise <br /> from the procedure. I also certify that I take full responsibility and waive any claims against The Lush <br /> Studio and/or my Technician to the fullest extent permitted by law from all liability whatsoever, for <br /> any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for <br /> personal injury or otherwise, including any direct and/or consequential damages, which result or arise <br /> from the application/implantation of permanent makeup or otherwise, whether caused by the <br /> negligence or fault of either the Technician, The Lush Studio or otherwise. <br /> Client's Signature: Date: <br /> -------------------------------------------------------------------------------------------------------- <br /> For Technician's use only: <br /> Technician's Name: Date: <br /> Client has initialed/signed all areas of this document and I have answered all questions. <br /> Microblade Type/Size: Lot#: <br /> Pigment Brand/Color(s): <br /> Other notes: <br />