MICROBEAUTY STUDIO
Permanent Makeup Service
Patient Data
Patient Name*
First Name Last Name
Gender*
Phone Number*
Area Code Phone Number
Email*
example@example.com
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Emergency Contact Person*
First Name Last Name
Emergency Contact Phone Number*
Area Code Phone Number
Medical / History Data
Do you have any of the following conditions?
Hypertension Heart issues Rashes Diabetes Problems healing wounds Issues blood Clooting or history of hemphelia History of keloid scarring History of cold sores or fever blisters History of anemia Seizure Spinal Cord Issues History of skin disease or skin sensitivity
Are you wearing any eye contact lenses?*
Yes No
Are you pregnant, breastfeed, or nursing? (Female)*
Yes No
Are you under the age of 18? yes or no*
Have you had botox in your forehead within 4 weeks of the appointment date?
Are you currently taking any medications? If yes, please list them below:
Technicians make no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent make-up applications. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible reasons for restricting you from receiving a tattoo, you must approve of the procedure and the color before the application of your permanent make-up.
Authorization
- I confirm that all information given in this form is true, complete, and accurate.
- I released this organization for any responsibility in case of accident, illness, or injury.
- I understand that with time the pigment can fade and will change according to metabolism, skin type, medication, age, smoking, alcohol, sun exposure, Retin-A and Glycolic acids.
- I understand that the process used to apply color is not a one step process and may require subsequent visits to achieve desired results. I further understand that the fee includes my first visit and one touch-up visit within two months of first appointment and the result of the procedure will be a permanent change
- I understand the nature of the procedure and possible complications, reactions or adverse effects that may occur as a result of the applied pigments. I fully understand this is a tattooing process, and have discussed any medical conditions
- I acknowledge that no assurance was offered about the outcome.
- I have read through the Frequently Asked Questions on the MicroBeauty website and agree to strictly adhere to such instructions.
- I understand that taking before and after pictures may be required and allow MicroBeauty Studio to use the photos for marketing or promotional services.
- I acknowledge by signing below, that I have been given the full opportunity to ask any and all questions which I might have about obtaining this procedure(s) from, Mariah Feser. I also acknowledge that all of my questions have been answered below to my full and total satisfaction. I specifically acknowledge that I have been advised of the fact and matters set below, and I agree as follows.
I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Mariah Feser shall perform permanent application of dyes to the skin of the releaser. Whereas releaser has been informed as to the methods and procedures concerning the result of such treatments, a scratch test will aslso be performed prior to the procedure, if requested by the client, to detect any signs of allergies. I hereby release, acquit and discharge Mariah Feser and any and all persons which are or might be claimed to be liable to me from all claims and demans or whatever nature, actions and causes of action, damages, cost, loss of service, expenses and compensation on account or in any way growing out of personal injuries and property damage to result at any time in the future, whether or not they are in contemplation of parties at the present time and whether or not they arise following the execution of the release as the as the result of treatment procedure rendered. Releaser agrees to indemnify the hold harmless of Mariah Feser for any loss, damage, claim, injury, or expense asserted against myself.
Signature of the Patient*
Clear
Date*
Month Day Year
Date
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to be spread mainly from person-to-person contact. As a a result provincial and federal health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups and people.
MICROBEAUTY STUDIO has put in place preventative measures to reduce the spread of COVID-19 with strict cleaning measures and a strong recommendation to wear masks during appointments if possible. Further, attending to appointments in the studio could increase your risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 by attending the appointment and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed or infected by COVID-19 at MicroBeauty Studio may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my family may experience or incur in connection with my attendance at MicroBeauty Studio
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MICROBEAUTY STUDIO

Patient Data

Medical / History Data

Authorization