Coco Beautdega | Lux Bodysugaring & Beautique Consent Form

Microblading | Lashlift & Tint | Henna Brows | Sunless Tanning


What is your procedure preference? *
Name *
Name
Preferred Method of Contact
Preferred Method of Contact
Home
Work
Cell
Date of Birth *
Date of Birth
Please answer the pre-qualifying questions below truthfully as giving false information can impede your results and possibly cause you more serious complications. Coco Beautdega and Lux Premier Beauty ARE NOT RESPONSIBLE for any adverse results occuring due to improper information given on this form. Any and all information will be kept CONFIDENTIAL and used solely for assessment of eligibility for proposed treatment. *
HEMOPHILIA *
DIABETES MELLITUS *
HEPATITIS A B C D E F *
HIV + *
SKIN DISEASES *
ECZEMA *
ALLERGIES *
AUTOIMMUNE DISEASE *
HERPES *
INFECTIOUS DISEASES/HIGH FEVER *
EPILEPSY *
CARDIOVASULAR PROBLEMS *
ARE YOU ON ANTICOAGULANTS? (BLOOD THINNERS) *
ARE YOU TAKING ANY MEDICATION ON A DAILY BASIS? *
DO YOU HAVE A PACEMAKER? *
DO YOU HAVE A PROBLEM WITH HEALING OF WOUNDS? *
TAKEN DRUGS OR ALCOHOL IN THE LAST 24 HOURS? *
SURGERY/EXPOSED TO RADIATION IN THE LAST 14 DAYS? *
ARE YOU PREGNANT OR NURSING? *
PRONE TO HYPERPIGMENTATION AFTER TRAUMA? *
HAVE YOU HAD MICROBLADING OR FIBROBLAST DONE BEFORE? *
ARE YOU 18 YEARS OF AGE OR OLDER? *
ARE YOU CAPABLE OF LAYING DOWN FOR AT LEAST 60 MINUTES (FOR LASH LIFT/TINT, YOUR EYES MUST REMAIN CLOSED FOR THIS LENGTH OF TIME)? *
I UNDERSTAND THAT GIVING FALSE INFORMATION CAN IMPEDE MY RESULTS AND THAT COCO BEAUTDEGA AND LUX PREMIER BEAUTY WILL NOT BE HELD RESPONSIBLE *
I UNDERSTAND THAT DEPENDING ON PROCEDURE SELECTED, THERE WILL BE FURTHER INSTRUCTIONS/QUESTIONS/INFORMATION GIVEN *
I GIVE PERMISSION FOR BEFORE AND AFTER PICTURES TO BE TAKEN AND POSSIBLY POSTED ON SOCIAL MEDIA *