Semi Permanent Makeup Consent Form

Name*

First NameLast Name

Email

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?*

Please answer the following question with full honesty and accuracy.

Have you had a chemical peels recently?

How often do you exfolate your skin and what do you use?

Have you had any injectable fillers such as Botox, Restylane, Juvederm etc.? If yes when

Have you had any complications with previous tattoos or permanent makeup before?

Are you currently undergoing radiation or chemo therapy?

Do you have any allergies to products containing “ Caine?” ie., Lidocaine etc.

Do you have a history of skin diseases? If YES, Please explain

CHECK IF YOU HAVE A HISTORY OF ANY OF THE FOLLOWING CONDITIONS:

Accutane treatments? How long have you been off the medications?

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

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

YesNo

If yes, what are your allergies?

Are you pregnant?

YesNo

I acknowledge and give consent to this permanent makeup studio to use images of my permanent procedure for marketing and, or publishing purposes in various media such as the internet, magazine, print*

YESNO

I understand this service is NON-REFUNDABLE.*

Yes

We understand that last minute emergencies occur and will make every effort to accommodate your full appointment but this is not always possible. If you are unable to make your scheduled appointment, please contact us as soon as possible to reschedule. We require 24 hours notice for no fee cancelations. A NON REFUNDABLE DEPOSIT is required to secure appointment. Deposit will be forfeited if rescheduling/Cancellations less than 24 hours from appointment time.*

Yes

I acknowledge that obtaining permanent make-up is my choice alone. The application of permanent make-up will result in a permanent change to my appearance, and that needles and pigments will penetrate the surface of my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent make-up to the original condition, and it is very costly to remove.Initial: blanks*

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, haemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thin my blood.Initial: blanks*

If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my permanent makeup procedure.Initial: blanks*

I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the permanent makeup, or any open wounds or lesions at the site of the tattoo.
I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures. Initial: blanks*

I have advised the Technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reaction to the permanent make-up procedure and further acknowledge that such reaction is possible.Initial: blanks*

I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have permanent make-up at this time.Initial: blanks*

I acknowledge infection is always possible as a result of permanent make-up application, and I agree to follow all suggested instructions concerning the care of the permanent make-up site while it is healing.Initial: blanks*

I understand I will have permanent makeup applied using appropriate instruments and sterilization techniques. I understand that the permanent makeup site usually takes 2 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors, and the management of the permanent makeup studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my permanent make-up, the procedure, and conduct used in my permanent procedure and assume all responsibility for the decision(s) made consenting to this permanent procedure.Initial: blanks*

I understand that inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.Initial: blanks*

I have been given the full opportunity to ask any questions regarding the semi-permanent cosmetic procedures and that all of my questions have been answered to my full and total satisfaction.Initial: blanks*

I have read and understood the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees on the benefits due to, or consequences of, these procedures. I further acknowledge that, at the time of signing this consent, I am of sound mind and capable of making independent decisions for myself.Initial: blanks*

By signing below, I verify that I have read and understand the above statements and agree to them.*

Date Signed*

Date