Eyeliner Embroidery Consent Form

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I am Aware & Agree To The Following

Not everyone is suitable for micro-pigmentation treatments. Here is a list of health & skin conditions that might prevent you from being a suitable candidate.
Pregnant, Breastfeeding, Diabetes mellitus, High blood sugar, High blood pressure, heart issues, or any health conditions that cause excessive or relaxed bleeding. Blood diseases, such as HIV, Hepatitis, etc.
Treatment can be done with the following conditions: Individuals who have high blood pressure or diabetes and on medications with doctors' approval. Has cancer & alopecia but with doctors' approval.
SKIN - Eczema, Rosacea, Seborrheic dermatitis, Psoriasis, Vitiligo, Keratosis, Herpes/Cold sores on/near treatment area, Keloids, Hives, Dermatographic urticaria, Trichotillomania, Thyroid, Steroids, Hypersensitive, Thinned, acned or excessively oily skin
If you have any of the above or your skin is continuously flaking, itching, or aggravated, chances are your skin is in a constant state of unrest and shedding and is not suitable for the treatment. The same goes for chronic skin conditions & hypersensitive skin as the inherent nature of this type of skin causes easy bleeding. Excessively oily skin can create hair strokes to blur out eventually and results in the powder effect.
MEDICATIONS & SUPPLEMENTS (X) You are not suitable for the treatment if you have been using the long term on any blood-thinning medications or products, as it may cause easy bleeding.
Examples : Immunosuppressive drugs, Blood thinners (anticoagulant therapy), Retinoids, Aspirin, Ibuprofen, Alcohol, Coumadin, Vitamin E, Acetate, Fish oil, Chemotherapy drugs, Immunomodulatory drug, TBF inhibitors.
Nicergoline (sermon) should not be taken at least five days before the treatment to prevent prolonged bleeding. Retinol or any derivates of vitamin products should not be taken at least 4-6 months before & after the treatment.
ALLERGIES (X) Lidocaine, Prilocaine, Benzocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate
I am aware of the above conditions and will proceed with the session

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