Permanent Make-Up

Permanent Make-Up

General Consent and Procedure Permit
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Please Check to indicate you understand and agree with the following completely.

No Warrant or Guarantee has been made to me as a result of this permanent makeup/correction procedure and the final result cannot be guaranteed.I accept responsibility for determining the colour, shape and position of the enhancement as agreed during the consultation process prior procedure.I am aware that a sensitivity reaction to anesthetics can occur and accept all responsibility if an allergic response occurs.There is a potential for discomfort during the procedure.Tattoos can only be removed with a surgical procedure and that any effective removal may leave permanent scarring or disfigurement.I have been given the opportunity to ask questions prior to the procedure.I understand and accept that each procedure is a process and I may require touch ups after the initial procedure as 100% success is not guaranteed. I AM AWARE TOUCH UPS ARE AND ADDITIONAL COST TO ME.I accept that the highest standards of hygiene are met and that sterile disposable needles are used for each individual client, procedure and visit.I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner. I understand that infection and possible scarring can occur if I do not adhere to the said instructions.To my knowledge I do not have any physical, mental, or medical impaired or disability that may affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old and am not under the influence of drugs or alcohol.For the purpose of documentation and marketing purposes I consent to before and after photos of my procedure.
If you are affected or related to any of the following please check beside.

DiabetesVitamin ADizziness or faintingBleeding DisorderHepatitisBruise or Bleed EasilyChemotherapyAccutane (in the last 6 months)HIV/AIDSRetin-A or RetiolAnemiaUse of Tanning BedsThyroid DisturbancesHeart ConditionNut AllergyTrichotillomaniaAlopeciaHistory of Cold Sores, HerpesEpilepsyBotox or Filler (Within 4 weeks)COVID-19 Vaccine(Within 4 weeks)
Are you currently pregnant or breastfeeding? Yes or No
Allergies:
Previous Cosmetics Tattooing: Yes No
Where:
On a Scale of 1-10 how oily is your skin? 1 being very dry and 10 being very oily.

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Wat type of service did you come for today? Click all that apply.

Ombre Powder BrowsCombo BrowsMicrobladingBrow CorrectionLip BlushLip LinerTop EyelinerBottom EyelinerTop & Bottom EyelinerLash EnhancmentFrecklesOther
I fully understnd the terms and conditions of the discloser and release agreement. I accept to waive any and all rights for any claim against BlackMoon Beauty and Eleventh Aveune Tattoos for any reason whatsoever.

I understand the technician will give me time post procedure to make sure I am happy with the finished product prior to clean up as any needed touch ups will only be done at future touch up appointment at least 4 weeks from today.
Name

First NameLast Name
Signature
Date

MonthDayYear
Date
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