Eyebrow Microblading & SPMUDisclaimer & Consent Form. Name * First Name Last Name DOB * MM DD YYYY Phone (###) ### #### Email * Emergency Contact * Please list your emergency contact & phone number Are your brows currently tinted? * Yes No Have you had Botox in the past two weeks? * Yes No Are you currently pregnant/breastfeeding? * Yes No Do you presently have, or a have a history of easy bleeding? * Yes No Have you had MRSA in the past 2 weeks? * Yes No Do you presently have, or a have a history of diabetes? * Yes No Do you presently have, or a have a history of Hepatitis A, B, C, D * Yes No Have you had a forehead or brow lift? * Yes No Have you had a facelift? * Yes No Do you presently have, or a have a history of with alcoholism? * Yes No Do you presently have, or a have a history of an abnormal heart condition? * Yes No Do you presently have, or a have a history of taking meds before dental work? * Yes No Have you had a chemical peel in the past two weeks? * Yes No Do you presently have, or a have a history of an autoimmune disorder? * Yes No Do you have oily skin? * Yes No Do you presently have, or a have a history of cancer * Yes No Do you presently have acne, or are on Accutane? * Yes No Are you presently going through radiation or chemotherapy? * Yes No Have you used a sunbed / been tanned by the sun in the last two weeks? * Yes No Do you presently have, or a have a history of Tumours, Growths, Cysts or Poor Scarring? * Yes No Do you have a history of difficulty numbing with dental work? * Yes No Are you or have you taken any blood thinners such as Aspirin, Clexane, Ibuprofen, Alcohol, Coumadin in the past 2 weeks? * Yes No Do you presently have, or a have a history of any allergies? * Yes No If 'yes' please list allergies below Any disorders that you know of that aren't listed I agree that all the information that is listed is true & accurate to the best of my knowledge * Yes No What services are you interested in? * Please select all that apply Microblading Microshading Blade & Shade Faux Freckles Today's Date * MM DD YYYY Privacy Statement * Here at Vy Brows Artistry, we take your privacy seriously and will only use your personal information to administer your account and to provide the treatments and services you have requested from us. Any personal and medical information you provide will only be used by our technicians in connection with your treatment and stored in a locked cabinet within the clinic at all times. The correct personal and medical information is necessary to carry out your treatment safely. If at any point you believe the information we hold is incorrect you may request to see this information and have it corrected or deleted. Your information will never be passed on to any third party apart from our online appointment diary. This will send you reminders and confirmations of your appointments via message. By Law and for insurance purposes your basic personal data i.e name, date of birth, address, medical details are required to be kept for a minimum of 5 years, after which it will be securely destroyed. Please indicate that you consent to receive appointment reminders and confirmations by text and for us to securely store your personal and medical information Yes No Photographic/Video Release Form I give my consent for any photographs or videos taken of my procedure at Vy Brows Aristry to be used on social media sites/websites for the purpose of advertising. Yes No Thank you!