Permanent Makeup Client Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Date of Birth

Date

Age?

How did you learn about us?

Referral Name/Other

Please answer the following question with full honesty and accuracy.

Semi Permanent Procedure

BrowsLip BlushingEyeliner

Are you taking any kind of medications within the last 6 months?

YesNo

Is it a prescribed medications?

YesNo

Please indicate the medications that you're currently taking

Must discontinue any form of blood thinners like aspirin 5 days prior to service, please consult physician.

Do you have any known allergies to food, medicine, or cosmetic products?

YesNo

If yes, what are your allergies?

Are you pregnant?

YesNo

Breast feeding?

Not recommended for those breast feeding, signing below states that you were informed and are aware of any risk given by your physician, and artist and they are not held responsible for any medically induced outcomes.

Skin Abnormalities?: ie: keloids, rosacea, scarring, radiotherapy, chemotherapy, on Accutane,, lupus, organ transplant, pacemaker, etc.

Not recommended for skin abnormal signing below states that you were informed and are aware of any risk given by your physician, and artist and they are not held responsible for any medically induced outcomes.

NO BLOOD THINNERS,, ALCOHOL OR COFFEE BEVERAGES THE DAY OF PROCEDURE!Please read all the sentences and sign the agreement.

I authorized Jj Glow Esthetics to perform a cosmetic enhancement upon me on this day. I was informed that semi-permanent cosmetic enhancement is the same as the process of tattoo and it is an advanced version of it. I completely understand that in some rare cases, allergic reactions may occur even after my disclosure of all known allergy history I may have due to the pigment. I accept all the responsibility, and I fully understand the health risk of it. I accept that I MAY REQUIRE more than one session depending on skin.. The pigment might fade before or after 3 years, and may leave a mark or residue of color. I understand the possible side effects of the procedure and will be able to diagnose if it is normal or not. I confirm that I do not have any physical, medical, and mental conditions that might get conflict with the procedure. I confirm that I will strictly follow the pre and post-procedure instructions given to me. I confirm that all information I entered in this form is accurate and true to the best of my knowledge. I hereby certify and give this clinic my full consent to perform the necessary procedure. By signing below, I confirm that I have read and understood the statements above.

Client Signature

Tech Signature

Date Signed

Date

Technician Only: pigment(s) used