CLIENT HEALTH HISTORY

Full Name:
DOB:
Address:
CITY:
STATE:
ZIP:
PHONE:
EMAIL:
Do you have any known allergic reactions or sensitivities to any topical or local anesthetics?
Yes No
Do you have any allergies (i.e. Polysporin, Bacitracin, Neosporin, Latex, etc.)?
Yes No
Are you allergic to lidocaine or any other numbing agents?
Yes No
Are you currently pregnant or breastfeeding?
Yes No
Do you bruise easily?
Yes No
Do you have any heart conditions or high blood pressure?
Yes No
Do you have or do you think you may have any blood-borne communicable disease such as HIV or Hepatitis?
Yes No
Do you have any serious medical conditions?
Yes No
Does your skin swell easily?
Yes No
Do you have diabetes, are you currently on any form of immunosuppressant therapy or any condition that may delay healing?
Yes No
Do you suffer from any form of Hyperpigmentary skin condition?
Yes No
Do you have any known personal history or family history of Methemoglobinemia?
Yes No
Have you ever had a Herpes Simplex Type 1 infection?
Yes No
Do you use Retin A or Hydroxyl (Glycolic) Acid preparations?
Yes No
Are you prone to keloid scarring, hypertrophic scarring, or any other form of excessive scarring condition?
Yes No
Do you have a bleeding disorder or take blood thinners?
Yes No
Are you allergic or sensitive to any metals?
Yes No
Have you had any form of cosmetic or surgical procedure, Radiotherapy, or Chemotherapy at any time within the last 6 months? (botox, injections, laser therapies, facelifts, etc.)
Yes No
Do you have any chronic or acute eye disease?
Yes No

The UNDERSIGNED acknowledges that () has explained the nature of the procedure, including the risks and dangers inherent therein. I HEREBY CONSENT to () performing eyebrow microblading treatment and its procedures on me and in consideration of her doing so, I hereby release and forever discharge () from all demands, damages, actions, or causes of action arising out of the performances of the said treatment procedures, which I, my heirs, executors, administrators or assign can, shall or may have. No refund on any treatment. I accept the above color, design, and payment terms in this contract.

I hereby consent to () taking photographs of the undersigned both before and after any procedures being undertaken by () at the request of the undersigned. It is further acknowledged that the undersigned authorizes () to use such photographs in compiling albums of its various clients to show potential clients the procedures completed. This release shall be deemed to have been made and shall be constructed following the Laws of the Province of Ontario.

SIGNATURE:
DATE:
TECHNICIAN SIGNATURE:
DATE: