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Microbabe Studio

CLIENT AND MODEL CONSULTATION FORM

PERSONAL INFORMATION

Please fill your name: *

Please enter your full name.

ADDRESS: *

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Email: * Please enter your email.

Phone: * Please enter your phone number.

REFERRED BY Please enter your name.

ALLERGIES

Do you have any allergies? (i.e. Latex, nickel, anesthetics, antibiotics) *

Yes

Please select at least one choice above.

If yes,please specify Please enter your answer here.

Please specify any other allergy concerns below: Please enter your answer here.

Botox: If yes, when did you last have botox? Please enter your answer here.

Are you planning more botox? * Please enter your answer here.

Would you say your eyebrow area is *

DRY

NORMAL

OILY

Please select at least one choice above.

Microbabe Studio Disclosure & Release forms

You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is not meant to frighten you. It is simply and effort to ensure you are informed so you may give or withhold your consent to the procedure.

Please read the statements below, checking the boxes before each one, to indicate you fully understand:

That no warranty or guarantee has been made to me as a result of this permanent makeup/camouflage/correction/removal procedure, the final result cannot be guaranteed * Please check it here.

That there may be risks and hazards related to the performance of this procedure planned for me * Please check it here.

I realize that there is potential for discomfort during the procedure and during the healing process * Please check it here.

There is a possibility of bleeding, swelling, and allergic reactions to the pigment * Please check it here.

That tattooing is considered permanent, however, it may fade with time * Please check it here.

That a tattoo can only be removed with a surgical procedure, and that any effective removal may leave scarring or disfigurement * Please check it here.

I have been given the opportunity to ask questions about the procedure, the hazards and risks involved * Please check it here.

I understand it is my responsibility to inform my technician of any questions or concerns I may have before the procedure begins * Please check it here.

I am not pregnant or breastfeeding * Please check it here.

I have no known allergies other than was stated on this form. I release Stephanie Henry and all of its representatives and subsidiaries of all claims for injury, seen or unseen that may occur as a result of this procedure. I * Please check it here.

I fully understand the questions, terms and conditions of this Disclosure & Release Agreement , and all have been explained to me. I accept to waive all my rights for any claim against Stephanie Henry and Refined Salon & Spa for any reasons may involve. This contract is to remain in effect for as long as I remain a client of Stephanie Henry and all its contents apply whenever work is being performed on myself by Stephanie. It is my responsibility to inform Stephanie whenever changes have occurred in my medical history. I certify that this disclosure and release agreement was completed by me and that all entries and information in it are true and complete to the best of my knowledge.

Client Name * Please enter your name.

Client Signature *

Click to sign

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Date *

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