Health Eligibility Criteria

Please carefully review the following list of disqualifying factors. Failure to disclose any relevant information may result in disqualification as a client. In such cases, your deposit will be forfeited. 

Thank you for your cooperation.

- Individuals with existing tattoos or microblading that have not faded at least 50% (please provide photos in natural daylight for approval).

- Individuals with known allergies to pigmentation or makeup.

- Individuals diagnosed with glaucoma or currently taking blood-thinning medications.

- Individuals with skin conditions such as eczema or psoriasis in the treatment area.

- Individuals under the age of 18.

- Individuals with active skin cancer in the intended treatment area.

- Individuals who have experienced post-inflammatory hyperpigmentation.

- Individuals with undiagnosed rashes or blisters in the treatment area.

- Individuals with transmittable blood conditions, including but not limited to Hepatitis or HIV.

- Individuals with diabetes.

- Individuals with mitral valve disorders or high blood pressure.

- Individuals diagnosed as hemophiliacs.

- Individuals with healing disorders.

- Individuals taking skin medications such as Antasure, Ro-Accutane, or steroids that thin and sensitize the skin.

- Individuals currently undergoing or scheduled for radiotherapy or chemotherapy treatments.

  - For individuals undergoing radiotherapy or chemotherapy, treatment must have concluded at least 42 days prior to the scheduled appointment.

- Individuals with a history of epilepsy who have experienced faint spells or seizures.

- Individuals who are pregnant and/or breastfeeding.

Please inform us if you have experienced any allergic reactions to topical anesthetics in the past.

• Full Name: ______________________________________
• Date of Birth: ____________________________________
• Address: ________________________________________
• Phone Number: ___________________________________
• Email Address: ___________________________________

Please answer the following questions truthfully and to the best of your knowledge. If you are unsure about any of the questions, please consult with your physician before completing this form.

Do you have any known allergies?

• Yes [ ] No [ ]
• If yes, please list: _______________________________________

           Are you currently taking any medications?

• Yes [ ] No [ ]
• If yes, please list: _______________________________________

            Do you have any chronic skin conditions (e.g., eczema, psoriasis, rosacea)?

• Yes [ ] No [ ]
• If yes, please specify: ____________________________________

            Do you have any heart conditions or take blood thinners (e.g., aspirin, Coumadin)?

• Yes [ ] No [ ]

           Do you have diabetes?

• Yes [ ] No [ ]
• If yes, is it controlled? Yes [ ] No [ ]

           Do you have any autoimmune diseases (e.g., lupus, rheumatoid arthritis)?

• Yes [ ] No [ ]

           Do you have a history of keloid scarring or hypertrophic scarring?

• Yes [ ] No [ ]

           Do you have any blood disorders or clotting issues?

• Yes [ ] No [ ]

        Are you pregnant or nursing?

• Yes [ ] No [ ]

       Have you undergone any recent surgeries?

• Yes [ ] No [ ]
• If yes, please specify: ____________________________________

         Do you have any infectious diseases (e.g., hepatitis, HIV)?

• Yes [ ] No [ ]

        Do you have any neurological disorders (e.g., epilepsy, seizures)?

• Yes [ ] No [ ]

        Do you use Retin-A, Accutane, or any other skin-thinning products?

• Yes [ ] No [ ]

        Do you have any other health conditions or concerns that may affect your eligibility for a permanent makeup tattoo?

• Yes [ ] No [ ]
• If yes, please specify: ____________________________________

          Have you consumed alcohol or recreational drugs in the past 24 hours?

• Yes [ ] No [ ]

       Have you had any cosmetic procedures (e.g., Botox, fillers) in the past month?

• Yes [ ] No [ ]
• If yes, please specify: ____________________________________

       Do you have a history of cold sores or herpes simplex virus?

• Yes [ ] No [ ]

       Do you have any medical implants (e.g., pacemaker, defibrillator)?

• Yes [ ] No [ ]

Disqualifying Factors:

Please carefully review the following list of disqualifying factors. Failure to disclose any relevant information may result in disqualification as a client. In such cases, your deposit will be forfeited. 

Thank you for your cooperation.

• Individuals with existing tattoos or microblading that have not faded at least 50% (please provide photos in natural daylight for approval).
• Individuals with known allergies to pigmentation or makeup.
• Individuals diagnosed with glaucoma or currently taking blood-thinning medications.
• Individuals with skin conditions such as eczema or psoriasis in the treatment area.
• Individuals under the age of 18.
• Individuals with active skin cancer in the intended treatment area.
• Individuals who have experienced post-inflammatory hyperpigmentation.
• Individuals with undiagnosed rashes or blisters in the treatment area.
• Individuals with transmittable blood conditions, including but not limited to Hepatitis or HIV.
• Individuals with diabetes.
• Individuals with mitral valve disorders or high blood pressure.
• Individuals diagnosed as hemophiliacs.
• Individuals with healing disorders.
• Individuals taking skin medications such as Antasure, Ro-Accutane, or steroids that thin and sensitize the skin.
• Individuals currently undergoing or scheduled for radiotherapy or chemotherapy treatments.
  • For individuals undergoing radiotherapy or chemotherapy, treatment must have concluded at least 42 days prior to the scheduled appointment.
• Individuals with a history of epilepsy who have experienced faint spells or seizures.
• Individuals who are pregnant and/or breastfeeding.

Allergic Reactions

Please inform us if you have experienced any allergic reactions to topical anesthetics in the past.

Consent and Acknowledgment

I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that withholding any medical information or providing inaccurate information may result in complications and that the technician has the right to refuse service if they believe it is unsafe to proceed.

• Print Name: ______________________________________
• Signature: _______________________________________
• Date: ___________________________________________

Technician's Use Only

• Technician Name: ___________________________________
• Review Date: ______________________________________
• Comments: _______________________________________