Consent Form

This is a consent form for the scalp micropigmentation or microblading procedure.
Name(Required)
Address(Required)
Emergency Contact Name(Required)
1. Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?(Required)

Due to COVID-19, please review and answer the following questions.
Do you have any of the following:  fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?(Required)

Due to COVID-19, please review and answer the following questions.
Have you traveled internationally in the last 14 days, or been in close contact with someone diagnosed with COVID-19?(Required)

Due to COVID-19, please review and answer the following questions.

Medical History

Have you ever received SMP before?(Required)
Are you pregnant?(Required)
Do you have a heart condition, epilepsy, or diabetes?(Required)

If yes please explain in other.
Are you a hemophiliac (bleeder) or on any medications that may cause bleeding or may hinder blood clotting?(Required)

If yes please explain in other.
Do you have any communicable diseases? (H.I.V., A.I.D.S., HEPATITIS) Please be honest(Required)

If yes please explain in other.
Are you under the influence of alcohol or drugs, prescribed or otherwise? Please be honest(Required)

If yes please explain in other.
Do you have any allergies? (Medicines or topical solutions)(Required)

If yes please explain in other.
Eminent barber & SMP Scalp Micro pigmentation (SMP) & Microblading (PMU) Consent/Release of Liability(Required)
MM slash DD slash YYYY
Consent(Required)