TK Client Consent and Medical History Form Client Full Name * First Name Last Name Email * Phone (###) ### #### Have you ever had cosmetic tattoo such as Eyeliner, Lip Blush, or microblading before? Yes No Have you ever had any adverse reactions/allergies? Yes No Have you received chemotherapy or radiation in the past year? Yes No Are you taking medication for blood thinning? Yes No Have you had any facial or dermatology serviced in the last 30 days? Yes No Have you had problems with healing wounds or do you scar/bruise easily? Yes No Have you undergone recent surgeries? Yes No Are you taking any medication or supplements? Yes No List any illnesses, medical conditions, or medical treatments you have recently received that would prohibit or compromise the treatment: Please read and sign below Although every precaution will be taken to ensure your safety and well-being before, during, and after your microblading procedure, please be aware of the following information and possible risks. Microblading and all permanent makeup can last 1-3 years depending on how my skin reacts to the procedure. I understand this is also a semi-permanent makeup procedure that may take numerous follow-ups/touch ups to get desired result. I have seen and agree with the pre-draw shape that my artist created. I understand that this is a guideline for the shape and size of my design and it may vary slightly once the procedure is done. I agree that there may be discomfort, pain, risks and hazard related to performing this procedure. Such as possibility of bleeding, swelling, redness and allergic reactions to pigments.I have received post care instructions and will follow them to ensure the best results of my procedure. There is no warranty or guarantee made to me as a result of this procedure and the final result cannot be guaranteed as results will vary. There are no refunds for this procedure. I release my therapist and its representatives and license technicians of all claims and injury, seen or unseen that may occur as a result of this procedure. I also understand there is no refunds after procedure takes place. * This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to treatment. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. I understand the aftercare instructions and will do my part to maintain my brows. By signing below, I verify that I have read and understand the above statements and agree to them. MEDICAL HISTORY Please answer the following Are you prone to keloid scarring, hypertrophic scarring, or any other form of excessive scarring condition? Yes No Have you taken a medication containing Isotretinoin (eg. Roaccutane) during the previous 12 months? Yes No Do you have chronic or acute skin diseases, such as herpes (including cold sores), psoriasis or eczema ? Yes No Sun or other light allergies or allergy symptoms), light sensitivity, or histamine reactions? Yes No Do you have Diabetes, currently on any form of immunosuppressant therapy? Yes No Have you ever had a Herpes Simplex Type 1 infection (also called cold sores/fever blisters)? Yes No Do you have a known allergy/sensitivity to any topical or local anaesthetics including dental anaesthetics? Yes No Do you have endocrine and autoimmune diseases, such as diabetes, porphyria, or lupus? Yes No Do you have any form of bleeding disorder, or are you taking any anticoagulants (blood thinners)? Yes No Have you had any Cosmetic/Surgical Procedure or Chemotherapy at any time during the post 6 months? Yes No Do you suffer from any form of hyper-pigmentation skin conditions? Yes No Do you have any skin conditions such as eczema, dermatitis, or rashes? Yes No Do you suffer with fainting, blackouts, or seizures? Yes No Do you have a cardiac pacemaker, Implanted Cardioverter Defibrillator (ICD) or abnormal blood pressure? Yes No Have you had any recent surgery or scar tissue in the area to be treated? Yes No Do you have a known allergy to any ingredients within tattoo pigments or hair dyes, or other dyes? Yes No Do you have an allergy or sensitivity to latex/rubber? Yes No Have you used any eyelash or eyebrow growth serums / creams in the past 4 weeks? Yes No Do you have any hormonal imbalance? Yes No Are you currently taking any medications/vitamins? Is there any additional information about you that we should know before starting your treatment? Please read and sign below This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to treatment. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. I understand the aftercare instructions and will do my part to maintain my brows. By signing below, I verify that I have read and understand the above statements and agree to them. Client Name (Signature): * Thank you for choosing TK Beaute. We look forward to working with you!