Permanent Makeup Consent Form

Permanent Makeup Consent Form

Personal Touch Permanent Makeup
Full Name*

First NameLast Name
Date of Service

MonthDayYear
Date
Email
example@example.com
Phone Number*
Date of Birth ( Must be 18 years of age or older)*

Month/ DateYear
How did you hear about us?*
Check the following that apply to you:

Currently being treated for cancerConsumed large amount of alcohol in the last 24 hoursCurrently using Lash Growth serums (if yes, stop 5 days prior to permanent eyeliner)Currently Pregnant or Nursing (if yes, unable to get permanent Makeup)Currently using Retin AProne to fainting or dizzinessReceived Botox or filler in the last 3 monthsProne to keloids (raised scars) or hypertrophic scarsHad a chemical peel or laser within the last 6 weeks
Please explain any yes answers of the above.
Check any of the following allergies that apply to you:

GlycerinNovocain / lidocaineEpinephrineDyesMetalsVaseline / A&D
Check all procedures that apply to this consent*

Permanent EyebrowsUpper Permanent EyelinerLower Permanent EyelinerNipple / Areola PigmentationRemoval
Are you currently taking any medication?*

Yes (Please list below)No
Medications
Check the following to agree and consent to the statement:*

I fully understand that Personal Touch Permanent Makeup, when preforming permanent cosmetics does not act in the capacity as a medical professional. The suggestions made by them are just suggestions. They are not to be construed as, or substituted for advice from a medical professional.I have received pre and post instructions (available on website ).I agree to release Personal Touch Permanent Makeup and the pigment manufacturer from any and all liability related to allergic reaction or any other reaction to applied pigments.I understand that Personal Touch Permanent Makeup is its own business and will not hold any other establishment liable.I have been told that this procedure could have some discomfort and I give my permission to use topical anesthetic to make me more comfortableI agree that should I have a complaint of any kind, I will notify Personal Touch Permanent Makeup immediately at 920.710.2889 Samantha 920.810.6530 DesireeFull Face or specific area photographs both before and after will be taken and used for the purpose of advertising and education.I understand that Permanent Makeup is not an exact science and everyone heals differently. I also understand with initial procedure there is a free follow up 4-6 weeks after and this is necessary to complete the finished look.I understand if I do not show up or do not provide a 24 hour notice for my free follow up that I will be charged for any further visits.I understand by submitting this form I am consenting to have permanent makeup done by Personal Touch Permanent Makeup.I agree to FULLY read the pre/post instructions for the procedure I'm consenting to prior to my appointment. I understand that adherence to the aftercare is directly related to my healed outcome results. ( After you hit submit below you will be redirected to these instructions on our website)I'm currently not under the influence of any mind altering substanance.
Esignature *

First NameLast Name
Should be Empty: