Restore and Rise Application – MBellish Studio by Maria

Full Name

Preferred Name/Pronouns

Phone

City, State

In your own words, please share your journey through chemotherapy and how it impacted your sense of self. Why would receiving restorative brow or lip enhancement be meaningful for you at this stage of your life?

Procedure Applying For

Your safety and healing are our priority. Please check any that apply and provide additional details if needed.

History of chemotherapy or radiation (please provide dates) Autoimmune condition Diabetes Blood-thinning medications Allergies (including anesthetics) Skin conditions (eczema, rosacea, psoriasis) History of keloid or hypertrophic scarring Cold sores / Herpes Other medical conditions

Please provide more details about the options you selected above. The more detail you can share, the better.

Are you currently under a doctor’s care?

For clients who have recently completed chemotherapy or are under active medical care, a doctor’s clearance may be required to ensure it is safe to proceed with a cosmetic tattoo procedure.

I understand

Doctor's Name

Clinic / Practice

Phone

I will provide a doctor’s letter of clearance.

I give permission for MBellish Studio to contact my doctor if needed.

I understand that restorative permanent makeup involves pigment implantation and that healing varies per individual. I acknowledge that minor swelling, redness, or sensitivity may occur and that touch-ups may be required.

I understand

Story & Photo Sharing Preference

Restore & Rise Application

Thank you for applying beautiful!