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License Number: #SR0067900
Contact us
(661) 312-6139
Microblading
Hairstroke
Eyeliner
Lips
About Us
Contact
Forms
Medical Release
Permanent Makeup Pre-procedure
Lip Post Procedure Care
Eyeliner Post Procedure Care
Eyebrow Post Procedure Care
Medical Release
Step
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- About You
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About You
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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California
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Delaware
District of Columbia
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Vermont
Virginia
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Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
MM slash DD slash YYYY
Cell Phone
*
Email
*
How Did Your Hear About By Laurelle?
Medical History
To avoid unforeseen complications, please answer the following Questions.
Are you at least 18 years of age?
Yes
No
Have you had any aspirin or blood thinners in the past week?
Yes
No
Any mood altering drugs within the last 8 hours?
Yes
No
Do you have a history of cold sores, herpes, or fever blisters?
Yes
No
Are you sensitive / allergic to latex?
Yes
No
Have you had a chemical peel or laser treatments?
Yes
No
When?
*
Did you have any problems healing?
Yes
No
Are you currently undergoing radiation or chemotherapy?
Yes
No
Are you currently using any Retin-A or Alpha-Hydroxy skin care products?
Yes
No
Previous problems with tattoos or has physicians advised you not to have a tattoo at this time?
Yes
No
Are you allergic to metal?
Yes
No
Have you ever had any semi-permanent makeup procedure before?
Yes
No
Are you on any immunosuppressive medication such as anti-inflammatories or steroids?
Yes
No
Are you allergic to topical antibiotic preparations or desensitizers?
Yes
No
Is there any history of skin diseases or remarkable skin sensitivities?
Yes
No
Are you currently taking any vitamins A or E in any form?
Yes
No
Are you pregnant or nursing?
Yes
No
Are you required to take antibiotics during dental or invasive medical procedures?
Yes
No
Do you wear contact lenses?
Yes
No
*
I understand the contact lenses MUST be removed during my eyeliner procedure and should not be replaced until the next day.
Medical History
Please select any of the following which may pertain to you
Heart Conditions
Allergies to Makeup
Accutane Treatment
Dry Eyes
Diabetes
Stroke
Chest Pains
Alopecia
Refractive Eye Surgery
Glacoma
Trichotillomania
Keloid/Hypertrophy of Scars
Epilepsy/Seizures
Shortness of Breath
Autoimmune Disorder
Cancer (Any)
Hepatitis/Jaundice
HIV
Kidnet Disease
Tendency to Develop Fever
Blister on The Lip
Oculare Herpes
Hyperpigmentation
Hypopigmentation
Tendency to Bleed Excessively from Minor Injuries
List any other medical conditions or issues not listed above
Primary Physician's Name
Phone Number
I acknowlege, understand and agree that:
*
the staff at By Laurelle do not practice medicine, does not accept health insurance, and have made no representation to the contrary.
*
Inks and dyes are not yet approved by the food and drug administration (FDA) and health consequences are unknown.
*
The information provided on this form is accurate and complete to the best of my knowledge, and that By Laurelle is not responsible for complications or problems arising from any incorrect or omitted information.
*
Some individuals will have complications related to semi-permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold By Laurelle and its employees and contractors harmless for same.
*
The staff at By Laurelle will use the information provided above to assess my suitability for the proposed micropigmentation services.
I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.
*
I agree
I acknowledge that complications as a result of semi-permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.
*
I agree
I realize that my body is unique and neither By Laurelle nor its employees or contractors can predict how my skin may react as a result of the procedure.
*
I agree
I have previously had micropigmentation performed by someone other than By Laurelle on the same area (brows, lips, etc) that I am asking By Laurelle to work on today.
*
Yes
No
I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which By Laurelle has no control. I understand that additional appointments after the initial and follow up appointments may be required, and will be billed at By Laurelle’s standard rates. I understand that By Laurelle can not predict the results in advance and can not guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold By Laurelle harmless from same.
*
I agree
I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.
*
I agree
I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my semi-permanent makeup, and that I must inform any future service provider that I have had micropigmentation applied. I understand and accept that such changes are not the fault of By Laurelle or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further semi-permanent makeup procedures.
*
I agree
I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.
*
I agree
I acknowledge that obtaining the semi-permanent makeup is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of By Laurelle and its employees and contractors reasonably necessary to perform the procedure.
*
I agree
I understand that I will have the opportunity to approve the design and color of the semi-permanent makeup to be applied, and I accept responsibility for same.
*
I agree
I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of By Laurelle.
*
I agree
[Optional/Requested] I consent to By Laurelle using “before & after” photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting By Laurelle, which will then discontinue use of said photo(s).
I agree
I have been given the full opportunity to ask any and all questions which I might have about obtaining semi-permanent cosmetic procedures from a micropigmentation specialist at By Laurelle, and that all of my questions have been answered to my full and total satisfaction.
*
I agree
If you have previously had micropigmentation performed by By Laurelle, has your medical history changed since you last filled out By Laurelle’s Medical Profile form?
*
Yes
No
Please Specfiy
*
Please select your desired service(s).
*
Eyebrows
Eyeliner
Lips
Post procedure care forms
Eyebrow Pigmentation
Eyeliner Pigmentation
Lip Pigmentation
I agree that I have reviewed all of the pre and post procedure forms regarding the service(s) that apply to me.
*
I agree
Signature
*
Date
*
MM slash DD slash YYYY
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