Surveypoint

Q1

Client

First Name

Q2

Client

Last Name

Q3

Phone Number

Q4

Email

Q5

By checking the following boxes, confirm that you willingly consent to the following terms and conditions:

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation.

I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments.

Corneal abrasions are a rareside effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure.

I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin.

I have read and understand the post-treatment home care instructions and understand how important it is to follow all instructions given to me for post-treatment care.

Q6

By checking the following boxes, confirm that you willingly consent to having the treatment during the COVID-19 pandemic:

I am aware of the risks of having hair services during the pandemic.

I understand that physical distancing of 6 feet may not be possible while in the salon receiving services.

I will follow the rules in order to minimize the spread of viruses. I understand that I must sanitize my hands before entering the salon and I must wear a mask that covers my mouth and nose while in common areas.

I confirm that I have not travelled domestically or internationally via public transportation within 14 days.

I do not have any of the following COVID-19 symptoms: cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste, loss of smell.

I have not contacted with anyone that have or may have COVID-19 symptoms or get infected within past 14 days.

Q7

Date

Q8

Microblading Consent And Appointment -Form Fill

Client

Client

Phone Number

Email

By checking the following boxes, confirm that you willingly consent to the following terms and conditions:

By checking the following boxes, confirm that you willingly consent to having the treatment during the COVID-19 pandemic:

Date

Client Signature