Consent Form

This form is designed to give information needed to make an informed choice of whether or not to undergo a Semi-Permanent Makeup application and give your consent should you choose to move forward.

Although Semi-Permanent Makeup and/or removal is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though technically semi-permanent, it does last several years.

All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are strictly adhered to.

This is considered a two part process and will consist of an initial session and a touch up session that MUST be completed within 6-10 weeks after the first session. Inablity to complete the touch up session will result in a new service price instead of the touch up price.

Initially the color the will appear more vibrant or darker compared to the end result. Within 5-7 days the color will fade 30-40% , soften, and look more natural. The pigment is semi-permanent and will fade over time. Additional touch ups are likely needed within 9 months to 2 years depending on your individual treatment, and how well aftercare is followed.
Permanent Makeup Consent Form
I have read and understand the above statements.
Booking Requirements

EXTREMELY IMPORTANT
You understand that upon submitting this form, it will be reviewed by my chosen artist and if there are any questions or concerns you will be notified.

You understand you must put down a $50 deposit PER service, to fully book your appointment. This deposit goes towards the cost of your service, and will be deducted from your balance at time of service.

Failure to cancel or reschedule before 48 hours of your appointment will result in forfeiture of your deposit. Deposit is transferable 1 time.

Cancellation within 24 hours of your appointment will result in 35% charge of the service or services booked.

No call no show will result in a 50% fee of total services booked.

NO REFUNDS and all sales are final.
Yes
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Yes, feel free to use them!No, please do not use them.
YesNo
Please upload a photo of your valid ID*

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Today's Date*

MonthDayYear
Date
Statement of Consent:

Please read and choose yes or no
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize Chanel Bates as my Technician to perform on my body the service I desire.
I understand the above*
Powder Brows (Machine work)Lash Line EnhancementLip BlushingColor CorrectionNew Customer with existing work touch up
YesNo
If you currently have permanent makeup, what do you have done and how long have you had it? Please describe below or Type NA if this does not apply.*
Please upload a photo of your face without makeup:*

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Client Medical History
Emergency Contact*

First NameLast Name
Phone Number of Emergency Contact*
Please enter a valid phone number.
Do you have or previously had any of the following:
YesNo
YesNo
YesNo
If yes, when was your last treatment, or when are you scheduled to get it? Write NA if this does not apply*
YesNo
If Yes, is it under control? Please explain
YesNo
YesNo
If yes, when? Write NA if this does not apply*
YesNo
YesNo
YesNo
YesNo
If Yes, when did you last get it done or when are you getting it done? Write NA if this does not apply*
YesNo
YesNo
YesNo
If Yes, what do you have? Is it under control? Write NA if not applicable*
YesNo
YesNo
YesNo
If yes, please explain. Write NA if not applicable*
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If Yes, what are they? Write NA if not applicable*
YesNo
Please list any medications you are currently taking:*
YesNo
If yes to the above and you are getting lip blushing, you MUST consult your Dr to recieve Acyclovir or Valtrex. 1 weeks worth, 3 days before your appt, day of, and 3 days after to suppress an outbreak. Without a suppressant lip blushing will cause an outbreak due to the trauma of tattooing the lips. There is also a chance a person may have HSV that lies dormant. While this is rare, an outbreak may occur.
YesNo
POSSIBLE RISKS, HAZARDS, or COMPLICATIONS
PAIN: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others.

INFECTION: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the area. See "after care" sheet for instructions on at home care.

UNEVEN PIGMENTATION: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance.

ASYMMETRY: Every effort will be made to avoid asymmetry, but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness.

EXCESSIVE SWELLING or BRUISING: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don't bruise or swell at all.

ANESTHETICS: Topical anesthetics are used to numb the area to be tattooed. lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now.

MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI Technician of any tattoos or permanent cosmetics. I understand that upon submitting this form, I will be guided to request my appointment date.
The alternative to these possibilities is to use traditional cosmetics and NOT undergo the Semi-Permanent Eyebrow or Make Up procedures. All tattoos are considered to be permanent and can cause scarring. It may have to be removed if dissatisfied, which can be costly, and invasive. If you have have any adverse reactions or infection please contact the Newton County Health Dept.
Yes
As stated in the booking requirements a valid credit card must be on file to reserve your appointment. Your card will only be charged under the guidelines of the booking requirements.

Credit Credit Information*

Deposit to book appointment

$50 deposit required to book appointment per service. This will be deducted from total the day your services are rendered. This is non refundable, and transferable one time. Please refer to booking requirements at the top of the page.

$50.00 Quantity
Item subtotal:$0.00

Credit Card

By signing below, I acknowledge that everything I have stated on this form is true and correct. If a false statement is made or medical history is incorrect, my permanent makeup artist cannot be held liable.
Signature*
Should be Empty:

Permanent Makeup Consent Form

Booking Requirements

Statement of Consent:

Client Medical History

Do you have or previously had any of the following:

POSSIBLE RISKS, HAZARDS, or COMPLICATIONS

Credit Card