Semi-Permanent Makeup Client Consent and Information Forms

CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE
Name*

First NameLast Name
Procedure Date*

MonthDayYear
Date of Birth- Must be over 18*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
IFull Name* am over the age of 18, am not under the influence of drugs
or alcohol and desire to receive the indicated permanent cosmetic procedure. The
general nature of cosmetic tattooing as well as the specific procedure to be performed has
been explained to me.
Signature

Clear
Procedure(s):Service name(s)* field.
Number of visits required:Number*.
Cost of Procedure:Cost*.
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, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. 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(s).
Initials*

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.
Initials*

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.
Initials*

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
Initials*

I give permission to use of my photos for the purpose of marketing. My pictures may appear in print or online.
Initials*
Client Signature:*

Clear
Date*

MonthDayYear
Technician Signature:*

Clear
Date*

MonthDayYear

Procedure Disclaimer
I am aware it is not possible to predict how durable and intensive the color will heal. The durability and color intensity depend on age, skin type, and environmental conditions of the treated person. I am aware the treatment with the pigmenting needles can cause temporary skin irritation and minor inflammation of the skin which usually disappears within 24-36 hours. For Lip Blush: If predisposed to cold sores, start taking medication immediately, as trauma to the lip can cause an outbreak and may affect pigment retention.

I have been informed the pigments will appear darker within the first few days immediately following the procedure and is not the final result. It is recommended to undergo a follow up touch-up treatment to lock in results. I have been informed the section of skin to be pigmented may be anesthetized/numbed with an anesthetic. I agree to inform my technician of any known allergies included allergies to anesthetic products.
Client Signature*

Clear
Date*

MonthDayYear
I hereby declare that I am not intoxicated and that I am fully aware of the treatment procedure and that I understand the above statement to be true. I give my consent to have Permanent Make-Up performed and assume full responsibility for the outcome. I do not and will not hold my technician responsible or liable should the results not be as discussed or as I had imagined keeping in mind everyone heals differently. I also understand there are no refunds for the PMU procedure. I will not dispute the charge with my bank for the debit or credit card transaction. This includes transfers I voluntarily made through Zelle, Cashapp, Venmo, Apple Pay, SquareUp, or PayPal sent to my technician Jennifer Gonzalez doing business as Lip Blush Guru LLC.
Client Signature*

Clear
Date*

MonthDayYear
Technician Signature*

Clear
Date*

MonthDayYear
Should be Empty:

CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE

CLIENT INFORMATION SHEET

Procedure Disclaimer