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Client History 

Client Name *
Client Name
Date Of Birth *
Date Of Birth
Art Procedure(s) To Be Performed: *
Rash? *
Pimples? *
Evidence of infection? *
Open lesions? *
Moles? *
Sunburn? *
General Health
Currently Pregnant *
Currently Nursing *
History of herpes infections *
Also known as cold sores or fever blisters
Diabetes *
Hemophilia *
Cardiac Valve Disease *
Currently using medication? *
Any medical conditions requiring antibiotic therapy prior to an invasive procedure such as dental work? *
Impaired by any drugs or alcohol or incapable of making an informed consent to the procedure(s) and aftercare instructions? *
Do you have any allergies? *
Do you have any tendency to become light-headed or dizzy during certain procedures such as dental work? *
The above information is correct to the best of my knowledge.
Informed Consent To Receive Body Art
Please read and check the boxes when you are certain you understand the implications of signing.
In consideration of receiving body art from
the practitioner at Eye Envy Microblading & Image Enhancement, Inc, (together with its employees, apprentices, and agents, the "Body Art Business")
I, *
confirm the following by checking each applicable item:
Notice*: Tattoo inks, dyes, and pigments that have not been approved by the federal Food and Drug Administration have health consqequences that are unknown.
I am the person of the legal ID presented as proof that I am at least 18 years of age. *
I am under the age of 18 years old and have the presence of my parent or guardian to recieve the body art.
(Applicable only to underage body part. N/A if not applicable).
I am not under the influence of alcohol or durgs that I am voluntarily submitting myself to recieve body art without duress or coercion. *
I acknowledge that the inforamtion that I have provided in the medical questionnaire is complete and true to the best of my knowledge. *
I understand the permanent nature of recieving body art and that removal can be expensive and may leave scars on the procedure site. *
The body art described or shown on the client record form is correctly placed to my specifications. *
All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instruction for the procedure I am about to recieve. *
I understand the restriction on physical activities such as bathing, recreational water activities, gardening, contact with animals, and the durations of the restrictions. *
I understand that any medical information obtained will be subject to the Federal Health Insurance Portability and Accountability Act of 1996 (HIPPA) *
I am aware that tattoo inks, dyes, and pigments used on the procedure site have not been approved by the Federal Food & Drug Administration, and that the heal consequences of using these products are unknown. *
I am aware of the signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of the procedure site, red streats going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site. *
I am aware of the risks for bloodborne pathogen exposure. *
I understand there is a possibility of getting an infection as a result of receiving body art particularly in the event that I do not take proper care of the procedure site. *
I will seak professional medical attention if signs and symptoms of infection occur. *
I have read and agree to the Privacy Policy *