POWDER LIPS CONSENT FORM

First Name *

Last Name *

Phone *

Email *

Date of birth

Age

Address

City

State

MEDICAL HISTORY

Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?

Do you use any medications that might affect the healing of the body art you wish to receive?

Do you have a history of herpes at the procedure site?

Do you have any other medical or skin conditions that affect the outcome of your procedure?

Is there any information you feel you should provide to the body art practitioner?

Any order risks of bloodborne pathogens exposure?

If you have any medical history above:

I confirm that I have a medical condition, and I have consulted with a healthcare professional/doctor regarding this condition. My healthcare professional/doctor has advised me that the microblading/permanent makeup procedure is safe for me to undergo, given my medical condition.

PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

In consideration of receiving BODY ART from Mai Nguyen, the practitioner at Heaven Brows (together with its employees, apprentices, and agents, the “Body Art Business”)

Note: The FDA does not regulate the inks and colors used in permanent makeup procedures.

AFTERCARE INSTRUCTIONS

The following written instructions were communicated to the client:

1. Information on the care of the procedure site.

2. Restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with animals for 7 days

3. Be aware of infection signs, such as increased redness, swelling, tenderness at the procedure site, red streaks extending from the area, elevated body temperature. These symptoms require immediate medical attention.

4. Instructions to call a physician if any of the addressed signs and symptoms appear or for any other reason related to the Body Art procedure(s).

5. If physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body Art facility and practitioner of the problem and the resolution by a physician or clinic. This information shall be placed in the client’s file.

INSTRUMENT LOG (to be filled by artist/practitioner)

If single-use, pre-packaged, pre-sterilized instruments and needles are used please maintain the following records:

(1) A record of purchase and use of all single-use instruments.

(2) A log of all procedures, including the names of the practitioner and client and the date of the procedure.

(3) Written proof on company or laboratory letterhead showing that the presterilized instruments have undergone a sterilization process. Written proof shall

clearly identify the instruments sterilized by name or item number and shall identify the lot or batch number of the sterilizer run.

Supplier

Instrument/Needle

Lot/ID Number

Sterilization Date Expiration

Color

Artist Name

Date Signed *

Signature *

Clear

By providing my phone number, I agree to receive text messages from the business regarding aftercare instructions, appointment reminders, and promotions.