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Microblading and Permanent Make Up Consent Form Name (Please print) Date of Birth Address city Zip Phone Number E-mail List medications taken in last 6 months: Are you pregnant or nursing? Y_ N_ Have you had: Chemotherapy or radiation in past year? Y_ N_ Chemical or laser peel in last 6 weeks? Y_ N_ AHA preparations in last 2 weeks? Y_ N_ Do you: Bruise or bleed easily? Y_ N_ Scar easily? Y_ N_ Have hypertrophic scars Y_ N_ Healing problems Y_ N_ Have keloid scars Y_ N_ Require Antibiotics Prior to Surgery or Dental Procedures Y_ N_ Have Other Risk Factors for Blood Borne Pathogens Y_ N_ I have or have had: Please circle any that apply: Allergic Reaction to Latex Allergic Reaction to Antibiotics Alopecia Anemia Cancer Circulatory Problems Clotting Issues Diabetes Epilepsy Fainting Spells or Dizziness Hair Loss History of Herpes Infection at the Procedure Site Heart Disease History of Hemophilia or other Bleeding Disorders History of Cardiac Valve Disease Artificial Heart Valves Hepatitis Herpes High or Low Blood Pressure HIV Liver disease Other Risk Factors for Blood Borne Pathogens Requirements for Antibiotics Prior to Surgery or Dental Procedures Sensitivity to Cosmetics Thyroid Disturbances Trichotillomania Tumors, Growths,or Cysts What are your expectations from this procedure? Microblading and Permanent Make Up is a type of cosmetic tattooing. You might be slightly uncomfortable,and there maybe some swelling, redness, and minor bleeding. Allow your technician to judge whether to proceed or terminate process. After a healing period of approximately 6 weeks, touch up procedures may be performed. The pigment will initially be darker than expected, but will begin to fade immediately. Inks are not FDA approved and health consequences are unknown. On rare occasions,there may be an allergic reaction to pigment and/or anesthetic. (A patch test will not guarantee absence of allergic reaction.) Very uncommon, but possible, is pigment migration. Infections can occur if aftercare instructions are not followed correctly. Microblading and Permanent Make Up cannot be performed on pregnant or nursing women, or anyone under 18 years. It is not recommended for oily skin. Seek medical attention for excessive swelling,inflammation,discharge,or any signs of infection. Questions? Ask your technician. I fully understand the information provided above and the permanent nature of the procedure. I have received aftercare information and I confirm that all of the information provided by me is correct and truthful. Client Signature Date Carmela Chavez Exhale salon 103 W Pine st. Lodi,CA 95240 MICRO BLADING and PERMANENT MAKE UP CLIENT CONSULTATION and MEDICAL HEALTH FORM 8/6/19