Permanent Makeup consent and medical health form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date of Birth*

Date

Gender

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you learn about us?*

Please answer the following question with full honesty and accuracy.

I am 18 or older*

YesNo

I am aware that permanent/ semi-permanent makeup enhancement is the same as a tattoo and it is an advanced version of it.*

YesNo

Have you taking any kind of medications within the last 6 months?*

YesNo

Is it a prescribed medications?

YesNo

Please list all medications.

Have you received chemotherapy or radiation in the past year?*

YesNo

Have you ever had an allergic reaction to one of the following?*

Have you ever had any of the following?*

Are you currently pregnant or nursing?*

YesNo

Please add a picture of your brows without makeup.*

Browse Files

What are the main concerns relating to your eyebrows?

Please add a picture of your brow inspiration.

Browse Files

What would you like to improve? Think about shape, color, density, thickness of your perfect brow.

Please read all the sentences and sign the agreement. I authorized Trenay Ulloa to perform a cosmetic enhancement upon me on this day. I was informed that permanent and semi-permanent cosmetic enhancement is the same as the process of a tattoo and it is an advanced version of it. I completely understand that in some rare cases, allergic reactions may occur even after my disclosure of all known allergy history I may have due to the pigment. I accept all the responsibility, and I fully understand the health risk of it. I accept that the pigment might fade before or after 1-3 years, and may leave a mark or residue of color. I understand the possible side effects of the procedure and will be able to diagnose if it is normal or not. I confirm that I do not have any physical, medical, and mental conditions that might conflict with the procedure. I confirm that I will strictly follow the pre and post-procedure instructions given to me. Infection can occur if post-care 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 the procedure, you should notify/discuss with your doctor. I confirm that all information I entered in this form is accurate and true to the best of my knowledge. I hereby certify and give this Trenay Ulloa my full consent to perform the necessary procedure. By signing below, I confirm that I have read and understood the statements above.

Date Signed*

Date

Signature *

Permanent Makeup consent and medical health form

Consent