Semi-Permanent Makeup Consent Form

Semi-Permanent Makeup - Consent Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to You:*
Google SearchSocial Media (Instagram, Facebook, etc.)Google Reviews/YelpReferral (Family/Friend/Coworker)Word of MouthOther
If you were referred by someone, we’d love to thank them! Please provide their name and phone number below:
Health History
YesNo
What area of the body is being treated? (Brows, Lips, Eyes)*

Have you ever been diagnosed with or experienced any of the following medical conditions?*

Rows	Yes	No
Alopecia
Trichotillomania
HIV
Hepatitis
Cancer (Current or Past)
Tumors, Growths, Cysts
Circulatory Problems
Anemia
Epilepsy
Fainting Spells/Dizziness
Artificial Heart Valve
High/Low Blood Pressure
Liver Disease
Thyroid Disturbances
Diabetes
Hemophilia
Prolonged Bleeding
Easy Bruising/Bleeding
Healing Issues (Slow Healing or Prone to Infections)
Hypertrophic or Keloid Scarring
Active Infections or Open Wounds

**If you answered yes to any of the following, please consult with your technician, as some conditions may require a doctor's note or additional precautions.**

Have you ever experienced an allergic reaction to any of the following?*

Rows	Yes	No
Lanolin
Latex
Vaseline
Medication
Metals
Hair Dyes
Foods
Lidocaine
Crayons
Glycerin
Paints

Location and description of tattoo area.
If you answered yes to any of the following, please describe:
YesNo
YesNo
YesNo
YesNo
Please list any medication you are currently taking:
YesNo
Please describe:
YesNo
YesNo

Have you had any of the following treatments in the past month?*

Rows	Yes	No
Botox or Fillers
Laser Skin Resurfacing
Chemical Peels
Cosmetic Surgery

If you answered yes to any of the following, please specify treatment and date of service:
YesNo
YesNo
Please describe:

Are you currently experiencing any of the following?*

Rows	Yes	No
Red or irritated eyes
Stuffy nose
Fever
Coughing

Is there any other health information you would like to share with us?
Service Information
NormalOilyDryCombinationSensitive
YesNo
If yes, please specify treatment and date of service:
What would you like to improve about your appearance? (e.g., shape, color, density, thickness):*
Please read the following statements carefully:
Semi-permanent makeup is a form of cosmetic tattooing designed to enhance features with results that typically last between 12 to 24 months. Semi-permanent makeup is not suitable for individuals who are pregnant, nursing, or under the age of 18.

While the procedure is generally safe, mild discomfort may occur during the process. Proper aftercare is crucial to minimize the risk of infections or complications, as well as to ensure optimal healing. It is common to experience some swelling, redness, minor bleeding, or scarring during the healing period. In rare cases, the pigment may shift slightly under the skin over time. Although allergic reactions to pigments or anesthetics are uncommon, they are still possible, and a negative patch test does not guarantee immunity to future reactions. If you undergo an MRI scan within three months of the procedure, be sure to inform your doctor in advance.

I acknowledge receiving detailed aftercare instructions and confirm that I fully understand the procedures outlined. Additionally, I affirm that all the information I have provided is accurate and truthful to the best of my knowledge.
Please read the following statements carefully. Semi-permanent make-up and microblading is a way of cosmetic tattooing, intended to be semi-permanent lasting average 12-24 months. On a rare occasion, the pigment may migrate under the skin. The procedure of microblading and semi-permanent make-up application may be uncomfortable. Although extremely rare, there might be an immediate or delayed allergic reaction to pigments. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. An allergic reaction to anaesthetic can occur. Semi-permanent cosmetics cannot be performed if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after microblading procedure, you should notify/discuss with your doctor. Possible scarring may occur.

I have received after care information and I’m fully aware of the aftercare procedures. I fully understand the information provided above & confirm that all information provided by me is correct and truthful.
Client name*

First NameLast Name
Client Signature*
Date Signed*

MonthDayYear
Date
**This section is for your GT Lash and Brows professional to complete:

Artist's Full Name: _____________________

Artist's Signature: _____________________ Date: __________

Artist's notes (Blades, Pigments, etc.):

_____________________________________________________

INFORMED CONSENT & WAIVER FOR SEMI-PERMANENT MAKEUP

Please read and sign below to indicate your understanding and acceptance of the terms outlined above.
Waiver & Release

I, {name}, authorize my GT Lash And Brows technician to perform the semi-permanent makeup procedure. I understand that this is a cosmetic tattooing procedure that involves implanting pigment into the skin to enhance the appearance of my eyebrows. I acknowledge that it is my responsibility to remain still during the procedure and to follow all pre- and post-care instructions provided by my technician.

I, {name}, have been fully informed about the methods and procedures involved in semi-permanent makeup and understand that results may vary based on factors such as skin type, medications, lifestyle, and adherence to aftercare. I acknowledge that this procedure is semi-permanent and that pigment particles may remain in the skin indefinitely. I also understand that the longevity of the results is affected by my individual healing process, exposure to sun, skincare products, and overall maintenance.

I, {name}, acknowledge the potential risks associated with this procedure, including but not limited to swelling, redness, tenderness, minor bruising, pigment migration, allergic reactions to pigments or numbing agents, and possible scabbing during healing. I understand that semi-permanent makeup typically lasts between one and two years, but touch-ups may be required to maintain the desired appearance.

If at any time I, {name}, feel discomfort, I will immediately inform the technician, who will address the issue or discontinue the session if necessary. Likewise, the technician reserves the right to discontinue the procedure if they believe it is in my best interest. I also understand that GT Lash And Brows is not responsible for any changes to my semi-permanent makeup caused by my medical conditions, medications, or lifestyle choices.

I, {name}, understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery, or other skin-altering procedures, it may result in adverse changes to my semi-permanent makeup procedure. I acknowledge that some of these potential adverse changes may not be correctable.

I, {name}, release and discharge GT Lash And Brows and its technicians from any liability associated with this procedure, including but not limited to allergic reactions, pigment retention issues, dissatisfaction with results, or unforeseen complications. I further agree to resolve any disputes through the American Arbitration Association, and I understand that if a decision is made in favor of one party, the prevailing party will be entitled to reasonable attorney fees and costs.

I, {name}, understand that any necessary corrections or touch-ups will be scheduled at an additional cost.

I, {name}, hereby grant GT Lash And Brows and its affiliates the absolute right and unrestricted permission to take, use, and display photographic images of my semi-permanent makeup procedure, including “before and after” photographs, in any form of media (print, digital, electronic, broadcast, or otherwise) for marketing, advertising, publicity, educational, and archival purposes. I waive any right to royalties or other compensation related to the use of these photographs and release GT Lash & Brows and its affiliates from any liability associated with their use.

Informed Consent

I, {name}, confirm that I am over the age of 18, am not pregnant or nursing, and am not under the influence of drugs or alcohol. I have disclosed all known medical conditions, allergies, and medications that may affect this procedure, and I take full responsibility for any adverse reactions that may occur as a result of my undisclosed health history.

I, {name}, acknowledge that the results of semi-permanent makeup may vary based on individual skin characteristics such as dryness, oiliness, sun exposure, pH balance, and the use of certain skincare products. I understand that oily skin types may experience healed results that are softer, more powdery, or blurred. Additionally, I understand that if I am prone to excessive bleeding, my pigment may heal with a cooler tone.

I, {name}, understand that any future cosmetic procedures, including but not limited to laser treatments, chemical peels, and injectables such as Botox or fillers, may alter or fade the pigment. I accept that these changes may not be correctable.
I acknowledge that the healing process may involve mild swelling, redness, tenderness, and scabbing, and that the true color of the pigment will develop over four to six weeks. I understand that additional sessions may be necessary to refine the results and that perfect results cannot be guaranteed in one appointment.

I, {name}, have been provided with detailed aftercare instructions and understand the importance of following them to ensure proper healing. I agree to avoid excessive sun exposure, sweating, swimming, and the use of harsh skincare products on the treated area during the healing process. I understand that failure to follow aftercare instructions may negatively affect my results and require additional touch-ups at my expense.

I, {name}, certify that I have read and signed the above paragraphs and have had an explanation of my understanding of the consent and procedure paperwork. I accept full responsibility for my decision to have this cosmetic semi-permanent pigmentation work done.

I, {name}, give permission for a GT Lash And Brows trained professional to perform my semi-permanent makeup procedure.
I, confirm that I am over the age of 18, am not pregnant or nursing, and am not under the influence of drugs or alcohol. I have disclosed all known medical conditions, allergies, and medications that may affect this procedure, and I take full responsibility for any adverse reactions that may occur as a result of my undisclosed health history.
I, blanks* , am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing, and desire to receive the indicated semi-permanent pigmentation procedure. The general nature of cosmetic micropigmentation, as well as the specific procedure to be performed, has been explained to me.
blanks*If an unforeseen condition arises in the course of the procedure, I authorize my therapist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances. I accept the responsibility for determining the color, shape and position of the semi-permanent make-up procedure as agreed during consultation. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-2 years. Even once the color fades, pigment itself may stay in the skin indefinitely.
(Initials)*I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit.
blanks*I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeated procedure.
(Initials)* The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged, thick, or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure aftercare.
(initials)*I understand that with oily skin types, microblading strokes can heal less crisp, expanded and/or blurry and may result in a powder-brow effect.
(Initials)*Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed.
(Initials)*I’ve been advised that the true color will be seen 4- 6 weeks after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition
(Initials)*I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.
(Initials)*I understand that if I am a bleeder the color of my results may heal “cooler”.
Patch Test
INITIAL ONE OF THE BELOW CHOICES TO WAIVE OR CONSENT PATCH TESTING:

I, {name}, consent to a patch test at least 24 hours before my procedure. I understand that this will require my appointment to be rescheduled, and GT Lash And Brows cancellation policy will apply. Initial Here to Consent

I, {name}, waive the patch test and I acknowledge that GT Lash And Brows is not responsible for reactions that may occur. Initial Here to Waive
Consent & Agreement

By signing below, you consent to the application of semi-permanent makeup at GT Lash And Brows. You understand that there are potential risks involved, including irritation, allergic reactions, pigment migration, and variations in healing outcomes. You agree to follow all aftercare instructions provided.
(Initials)*I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my semi-permanent make-up procedure. I acknowledge some of these potential adverse changes may not be correctable.
I certify that I have read and signed the above paragraphs and have had an explanation to my understanding, the consent and procedure paperwork. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.
I, (Client's Name)* , give, GT Lash and Brows trained professional, permission to perform my semi-permanent make-up procedure.
Name*

First NameLast Name
By signing, I confirm that I have read and understood all the terms and conditions of this service.*
Date Signed*

MonthDayYear
Date
**This section is for your GT Lash and Brows professional to complete:

Artist's Full Name: Loi Gia Tran

Artist's Signature:

Date:
Signature
Should be Empty:

Semi-Permanent Makeup - Consent Form

Emergency Contact Information

Health History

Service Information

INFORMED CONSENT & WAIVER FOR SEMI-PERMANENT MAKEUP

Patch Test