Permanent Cosmetics Consent Form

  • Permanent Cosmetics Consent & Release Form

    Client Information (ALL FIELDS REQUIRED)

  • SECTION A:

  •  - -
  • Format: (000) 000-0000.
  •  - -
  • Format: (000) 000-0000.

  • SECTION B:

  • SECTION C:

    Permanent Cosmetics Consent Form

  • CLIENT DISQUALIFICATIONS:

    • Ages 18+ only
    • Pregnant or nursing
    • Any transmittable blood related conditions such as HIV/AIDS or Hepatitis
    • Any skin allergies to pigment or makeup
    • Taking any blood thinning medications
    • Have any skin concerns on the procedure area such as: eczema, acne, psoriasis, keloids, rosacea, rash, blisters, etc.
    • Have active cancer or scheduled for radiotherapy or chemotherapy
    • Have experience with hyper-pigmentation
    • If the client is diabetic, a doctor's note is required for clearance
    • Any unknown medications or health situations (thyroid disorders, hypertension, anemia, etc.) must be approved by a doctor 
    • Botox and facial chemical peels must be scheduled at least 30 days before and after the appointment
    • Any COVID-19 Vaccinations or Boosters must be scheduled 2 weeks prior or after the appointment
    • Anyone currently taking or have taken Accutane or steroids within the last year
    • Anyone epileptic or has experienced faint spells or seizures.

  • I have read the disqualifications listed above and will inform the artist of any changes. I agree that I do no have any condition(s) that would make the requested treatment unsuitable and can proceed with the Permanent Makeup Procedure or service listed above.

    By signing below, I agree that I have completed this form to the best of my ability and knowledge and that this form was completed by me only.

  • SECTION D:

    Please read and INITIAL each APPLICABLE statement below carefully:

  • 1. I certify that I am over the age of 18.

    2. Brows are sisters, not twins. Your natural muscle pull will allow us to get them as symmetrical as possible.

    3. I have been informed of the nature, risks, possible complications, and consequences of a Permanent Makeup Procedure.
       
    4. I fully understand that this is a tattoo process and therefore not an exact science, but an art. I request the semi-permanent cosmetic procedure(s) and accept the permanence of the procedure as well as the possible complications and consequences of that procedure(s).

     5. I certify that I am not under the influence of drugs or alcohol and I am not pregnant or nursing.

      6.  I understand that there is a certain level of discomfort associated with the procedure and that each person has their own threshold level for discomfort. Upon consent, my artist may apply topical anesthetics to alleviate discomfort. I understand that there is a small chance of an allergic reaction to topical anesthetics.

    7. I understand that skin treatments (Retin A, Renova, Alpha Hydroxy and Glycolic Acids, laser hair removal, plastic surgery, or other skin altering procedures) may result in adverse changes to my permanent makeup procedure.

     8. I understand that sun, tanning beds, pools, some skincare products, and medications can affect my permanent makeup procedure.

     9.  I understand that successful saturation can NOT be guaranteed due to hidden scar tissue. I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during, and/or following the procedures such as infection, poor color retention, and hyperpigmentation.

     10.  I understand that this procedure is permanent in nature, but will fade over time. This fading can alter the original color and that this determines it is time for a touch-up or color boost to maintain the color.

     11.  I accept the responsibility of explaining to my artist my desire for specific colors, shapes, and positioning for any procedure done today.   

    12. I understand that after my service, there will be no refunds. No exceptions.

      13.  I acknowledge that obtaining permanent makeup is my choice alone. I understand that the procedure will result in permanent change to my appearance, and that the needs and pigments will go into my skin using only sterilized instruments along with proper technique.

      14.  I understand that infection is always possible as a result of permanent makeup application, and I agree to follow all suggested after-care instructions while it is healing. I also acknowledge that once I leave out of the artist's presence, I am now responsible for my own healing results and any infections or problems that may arise with the permanent makeup result.

     15.  I am aware that if an infection occurs after I have received permanent makeup, I am to seek help from a medical professional right away and contact my artist in that regard.

      16. Photos and videos are required for insurance purposes and may be used on social media platforms, for marketing, and educational purposes.

      17. To my knowledge, I do not have a physical, mental, medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a permanent makeup procedure.

     18.  If a dispute arises out of or relates to this contract or the alleged breach thereof, and if the dispute is not settled through negotiation, the parties agree first to try in good faith to settle the dispute by mediation within 30 days before resorting to arbitration, litigation, or some other dispute resolution procedure.

     19. I am aware that if I am to receive a Magnetic Resonance Imaging (MRI) after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics.

    20. Pigments and Machines are not FDA approved, but are approved by the Health Department.

     21. I give consent to confer with my physicians for medical information required for the safety of my procedure.

    22.  If I had permanent makeup performed previously by another artist, I will not hold Alysha Mantanona-Aganon, Boujee Beauty by Alysha Ashley, The Boujee Ink Studio PMU, responsible for any allergic contraindications and that mulitple touch-up appointments may be required to obtain the final, desired result. Additional touch-up appointments are at my expense.

     23.  I understand that it is my responsibility to book my touch up accordingly to the time frame and each touch up's fee is accordingly to the time frame.

      24.  I understand that the healing process takes two weeks or longer to heal. And I understand that the actual color of the pigment may be modified after the procedure due to the tone, color and type of my skin.

     25. I agree to release and forever discharge and hold harmless of the artist, all employees, contractors, and the salon for any and all claims of negligence, damages, or legal actions arising from or connected in any way with my permanent makeup procedure.

      26.  I understand that I must wait one full year following any tattoo/PMU procedure before donating blood, per Red Cross guidelines. I agree to inform my doctor of my permanent cosmetic enhancement if I require and MRI scan within a 3-month period of receiving the procedure.

    Please proceed to signature if you are a brow client.


    FOR LIP BLUSH CLIENTS ONLY:
       I am aware if I have had a previous outbreak of cold sores/herpes and receive lip enhancement, I may have an outbreak again following the procedure. I have been made aware that anti-herpes medication is available over the counter or on prescription and has been show to prevent or minimize such outbreaks.

     I understand that I may experience dry lips for up to two weeks following permanent cosmetic lip enhancement.

       I acknowledge that if I am also a tobacco user, I understand that the healing process may be negatively affected and I may have difficulty with color retention.

  • By signing below, I agree to the following:

    I have thoroughly read the risks and conditions listed above and that they have been explained to me with full understanding. I understand the risks and alternatives involved in this/these procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I accept full responsibility for the decision to have this cosmetic tattoo work done and understand that any complication that may arise during and/or foloowing the procedure(s) to be performed at my request hereby releases Boujee Beauty by Alysha Ashley from all liabilities associated with the above indicated procedure. I acknowledge that I have reviewed and approved the material given to me. 

  • SECTION E:

    PLEASE REVIEW THE POLICY BELOW:

  • The procedure will not start until you have agreed on the shape that is flattering to your facial features. Please make sure you are completely satisfied with the technique you choose (eyebrows, lips) before the procedure begins and before leaving the studio.

     

    Everyone is different and can respond to topical numbing and tattoo pigment ink differently. How much you bleed will affect the outcome result and therefore require additional appointments to acheive the desired result.

     

    Photos taken during and after your enhancement may be posted on our social media by us and us only. (For marketing purposes, our pictures may appear on our social media websites and on our webpage.)

     

    For schedule changes please provide a minimum of 72-hour notice from the time of your scheduled appointment. Any notice given after this time period will result in forfeiture of the deposit. A new deposit will be required to book another appointment. (Reschedules will be based on current availability and ONLY two reschedules are allowed.)

     
    Please confirm your appointment 72 hours prior. Appointments not confirmed 24 hours prior to appointment will automatically be cancelled and considered a No call/no show (see below for details.)

     

    No call/no show and changes made less than 24 hours prior to scheduled appointment will automatically forfeit their deposit and CHARGED 50% of remaining balance of service to be performed. No call/no show will NOT be allowed to reschedule.  
     

     If you are more than 10 minutes late, your appointment will be cancelled and your deposit will be forfeited. Additional deposit required to reschedule based on current availability. 

     
     I understand that things can come up, ALWAYS communicate with me ahead of time whenever feasible. 

     
    It is the client’s responsibility to read policies, precare instructions, and appointment reminders (email sent 3 days prior to appointment) in its entirety; once deposit has been made, it is an automatic agreement to accept and comply. 

     

    We reserve the right to refuse service to anyone.

     

    Our prices are subject to change at any time and without notice.

     

    A second session is recommended between 5-12 weeks from the initial procedure to ensure the desired result. Second session will be determined on the timeframe upon your return. It is your responsibility to book this with enough notice within the timeframe. On rare occasion, a client may need a third or fourth session due to having a skin type that is more resistant. The client will be charged accordingly.

     

    Your satisfactory is our priority. The results of the procedure is determined in part by the nature of the pathology of skin type and also factors such as current medications, skin characteristics (dryness, oiliness, thickness, sun-damaged, color, chemically-damaged, etc.), natural skin undertones mixing with pigment color, personal pH balance of skin, tanning booths, fruit acids, AHA's, Retin A use, alcohol intake, smoking, sun exposure, improper skin care, and adhering to aftercare instructions. These factors can interfere. We cannot guarantee 100% successful result to clients because everyone takes in permanent makeup differently. 

     

    There are no refunds as we have carried out and performed the scheduled service.

     

    I have read and understand everything that was provided in this form and they have been explained to me. I did not just sign the document. I accept full responsibility for any complication that may arise or result during or after the following cosmetic procedure (s) to be performed at my request.

     

    I have read and agree to the policy above.

  •  - -
  •  - -

  • *FOR ARTIST’S USE ONLY* PLEASE SCROLL DOWN & CLICK “SUBMIT”

    Procedural Notes (**Artist's Use Only**)
  • Should be Empty: