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Consent Form
This is a consent form for the scalp micropigmentation or microblading procedure.
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
(Required)
D.O.B.
(Required)
Age
(Required)
Driver’s license or I.D. #
Email
(Required)
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(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)
Yes
No
Other
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)
Yes
No
Other
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)
Yes
No
Other
Due to COVID-19, please review and answer the following questions.
Medical History
Have you ever received SMP before?
(Required)
Yes
No
Are you pregnant?
(Required)
Yes
No
Do you have a heart condition, epilepsy, or diabetes?
(Required)
Yes
No
Other
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)
Yes
No
Other
If yes please explain in other.
Do you have any communicable diseases? (H.I.V., A.I.D.S., HEPATITIS) Please be honest
(Required)
Yes
No
Other
If yes please explain in other.
Are you under the influence of alcohol or drugs, prescribed or otherwise? Please be honest
(Required)
Yes
No
Other
If yes please explain in other.
Do you have any allergies? (Medicines or topical solutions)
(Required)
Yes
No
Other
If yes please explain in other.
Eminent barber & SMP Scalp Micro pigmentation (SMP) & Microblading (PMU) Consent/Release of Liability
(Required)
1. To my knowledge, I do not have any mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to receive SMP or PMU at this time.
2. I agree to follow all instructions concerning the care of my SMP or PMU while it’s healing. I agree that any touch up work, due to my negligence, will be done at my own expense.
3. Being of sound mind and body, I hereby release any and all employees, agents or persons representing Eminent SMP.. LLC from all responsibility. I agree not to sue a Eminent SMP.. LLC, or its heirs or assigns in connection with any and all damages, claims, demands, rights and causes of action of whatever kind or nature based upon injuries or property damages to or death of myself or any other persons arising from my decisions to have SMP or PMU work at this time, whether or not caused by any negligence of Eminent SMP.. LLC employees.
4. I acknowledge it is not reasonably possible for the representatives and employees of Eminent SMP.. LLC to determine whether I might have an allergic reaction to the pigments or processes used in my SMP or PMU, and I agree to accept the risk that such a reaction is possible.
5. I agree for myself, my heirs, assigns and legal representatives to hold harmless from all damages, actions, causes of action, claim judgments, costs of litigation, attorney’s fees and all other costs and expenses which might arise from my decision to have SMP or PMU done by Eminent Barber & SMP LLC.
6. I have been advised that SMP or PMU will be permanent and that it can only be removed with a laser procedure, and that any effective removal may possibly leave permanent scarring and disfigurement. This cautionary notice is required to be provided to me by the health department and I hereby acknowledge receipt of this formal notice
7. I swear or affirm and agree that the above information is true and correct. I have been provided with information describing the SMP or PMU procedure to be performed and instructions on after care. I have been made aware that if I have any signs or symptoms of infection, such as swelling, pain, redness, warmth, fever, unusual discharge or odor to contact my physician. It is also my responsibility to take care of the treated site according to the instructions provided both verbally and in writing.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Consent
(Required)
I agree to the consent form.
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