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Pre-Treatment

Consent for Long-Term (Permanent)

Makeup Procedure

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HYDRAFACIAL | LASH EXTENSIONS | MICROBALDING | LASH AND BROW LIFT/TINT | AND MORE

Everett , WA

Client's information

Full Name

Date of Birth
Month
Day
Year

The procedure chosen by the client

PLEASE READ CAREFULLY AND SELECT REQUIRED PROCEDURE

The Client hereby confirms that he/she wants to have:

made to him/her: the injection of a special colour (pigment) in the skin in the facial area to intensify the shape of eyebrows in accordance with the procedure adopted by the authorized institution (a hygienic standard or etc.) in the country in which the procedure is performed.

To perform the procedure chosen by the Client safely, the Client hereby is submitting information by checking boxes by “x” respectively. If the Client deems it necessary, he/she indicates additional information on supplementary pages, which is that the Client indicates diseases he/she has or/and medicines he/she administers.

HEALTH & SAFETY QUESTIONNAIRE

Hemophilia
Yes
No
Diabetes mellitus
Yes
No
Hepatitis A, B, C, D, E, F
Yes
No
HIV
Yes
No
Skin diseases
Yes
No
Eczema
Yes
No
Allergies
Yes
No
Autoimmune diseases
Yes
No
Are you prone to herpes
Yes
No
Infectious diseases
Yes
No
High fever
Yes
No
Epilepsy
Yes
No
Cardiovascular problems
Yes
No
Are you taking a medication for blood thinning (anticoagulants)?
Yes
No
Are you pregnant?
Yes
No
Are you taking any medications on a daily basis?
Yes
No
Do you have a pacemaker
Yes
No
Do you have problems with healing of wounds?
Yes
No
Have you consumed drugs or alcohol in the last 24 hours
Yes
No
Did you undergo a surgery in the last 14 days, where you were exposed to radiation or did you have any other medical interventions?
Yes
No
Did you have any surgery or inpatient medical treatment in the last 14 days?
Yes
No
Menstruation on the date of performance of a procedure (increased sensitivity to pain and a local swelling is possible after a procedure if the procedure is made immediately prior or during the first days of menstruation)?
Yes
No
Are you sensitive to pain, blood or fear of needles?
Yes
No
Other problems: recently made chemical peelings, other procedures, facial surgeries, skin sensitivity to mechanical actions, removals, and etc.?
Yes
No

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real customers getting beautiful.

Blourin Beauty Salon

GET IN TOUCH

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Sunday to Friday  9:30 am - 8:30 pm

12811 8th Ave W Suite B-103, Everett, WA

​

925-557-5949

contact@blourinbeautysalon.com

© 2025 Blourin Beauty.  All Rights Reserved.

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