Consent to application of permanent makeup Procedure

First Name   Last Name   

Today's Date         

DOB    

  Street Address  
 Address Line 2   City   State   Zip   
 Home      Phone Number       
Cell      Phone Number    
Work      Phone Number   
Email   * Aftercare instructions will be provided here

Emergency Contact

First Name   Last Name   
Relationship blank
 Phone Number   

Please write exactly how you would like your name to appear when being referenced/tagged:
*Not Mandatory
I.G. blanks Facebook blank Pinterest   Blank   

Do you have any allergies to any of the Following? If other, please explain.
Latex   Glycern   PABA   Epinephrine   Caine Products   Other   None   blanks

Have you ever had permanent makeup done before?   Yes   No   
By Whom First Name   Last Name   Business Name      
and were you pleased with the results?   Yes 1   No        

I accept the responsibility for explaining to the performing technician my desire for specific color, shape, and position for eyebrows, eyeliner, and lip liner.

I understand that implanted pigment can turn color or fade over time due to circumstances beyond the control of the performing technician and alter the original pigment color.

I understand that since permanent makeup is an art and not a science, the performing technician cannot guarantee the outcome of the procedure. There are so many variables (medications, illness, skin care routine, etc.) related to each client that affect the outcome of any permanent makeup procedure.

I understand that I will need to maintain the color with future applications. Sun, skin care products, pools, and other factors can contribute to pigment fading.

The nature of the proposed permanent makeup procedure has been explained.

I understand and accept all risks and possible complications that may arise from this procedure.

Initial: blanks      

Do you have botox or other injections to the face?   Yes   No  
If yes, Where blanks & When      

Do you use Retin A, Renova, other retinol products, glycolic acids regularly?  Yes   No   
If yes, please confirm you have stopped at least two weeks prior to today's procedure.     Please Select Confirm Don't Confirm    

Have you used Accutane in the last 18 months?    Yes   No   
If yes, please confirm you have stopped at least 18 months prior to today's procedure Initials:    Please Select Confirm Don't Confirm    

Do you use or plan to use Latisse?    Yes   No   
If yes, please confirm that you acknowledge that the use Latisse prior to the procedure or before healing may lead to extreme irritation and loss of pigment. Initials:      

Do you take any of the following medications? (Circle all that apply): 
Accutane   Aspirin   Anabuse   Anti-coagulants   Blood thinners   Steroids   Insulin   Synthroid   High blood pressure   Neither      

I will/have not tan(ed) for at least 14 days before or after the procedure.   
Initial
Please check any of the following conditions that you currently have.
Blepharitis   Dermatits   Pregnant   Heart Problems   HIV/Aids   Hepatitis   Seizures   Fainting   Blood Disorders   Retin A   Allergies   Shingles   Autoimmune Disorders   Lupus   Diabetes   Cancer   Eye disorder   Scar Tissue   Surgeries   Keloids   Cold Sores   Plastic Surgery   Facial Trauma   Mental Health   Thyroid   Metal Allergies   Alopecia      Asthma   Hyperpigmentation   Sinusitis   Lip Injections   Trichotillomania   Hermatomas   Glaucoma   Dry Eye   Hemophilia   Conjunctivitis   Cosmetic Allergies   Lip Implants   Hypopigmentation   Radiation   Botox Or Similar   Bruise easily   Collagen   Bleed Easily      Chemotherapy   Mastectomy   Epilepsy   Hormone therapy   Oily skin   Dryskin   Combinaton Skin   Healing Problems   Chapped lips   Accutane   Latisse   Neither   

I acknowledge that the proposed procedure(s) involved risks inherent in the procedure and the possibility of complications during the procedure. Those complications can be, but not limited
to, infections, misplacement of pigment, poor color retention, or hyperpigmentation. initial

Precautionary Coronavirus Liability Release Form

Due to the ongoing 2019-2020 novel SARS-COV-2 (COVID-19) outbreak, we are taking extra precautions with all clients during these times. Each client should review health history, as well as sanitation and disinfecting practices recommended by the CDC. Please complete the following and sign below.
I   Client Name   agree to the following: I understand the symptoms of COVID-19 are fever, fatigue, dry cough, and difficulty in breathing. As such I affirm that I, as well as all household members, do not currently nor have experienced the listed symptoms within the last 14 days. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days. I affirm that I, as well as all household members, have not traveled outside the United States, or traveled to any country, outside of our own, that is considered a hot spot for COVID-19 as stated by the CDC or WHO within 30

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure.
There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction.
I consent YES or waive NO the patch test.   Yes   No   If waived, I release the technician from liability if I develop an allergic reaction to the pigment.

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.    Please Select I acknowledge    
I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.  Please Select I acknowledge    
I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.
Client Name   Signature      
Technician
First Name   Last Name