Consent Form for Permanent Makeup

Name

First NameLast Name

Date

MonthDayYear

I specifically acknowledge that I have been advised of the matters set forth below and agree as follows:

Rows	I agree
1. I acknowledge that obtaining permanent make-up is my choice alone. The application of permanent makeup will result in a permanent change to my appearance and the needles and inks will go into my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent make-up to the original condition and it is very costly to remove
2. I do not suffer from any medical or skin conditions such as, but not limited to: keloid, hypertrophic scarring, psoriasis at the site of permanent make-up, or any open wounds or lesions at the site of tattoo
3. I am not pregnant or nursing. I do not have history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to lates or antibiotics, hemophilia or other bleeding disorders. I do not have cardiac valve disease, suffer from any heart conditions, or take medication that thins my blood.
4. I have advised the technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is reasonably possible for the technician to determine whether I might have an allergic reaction to the permanent make-up process and further acknowledge that such reaction is possible.
5. I do not have history of medication use or currently using medication, including prescribed antibiotics prior to dental or surgical procedures
6. I have truthfully represented to the technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have physical, mental, or medical impairment or disability that may affect my well-being as a direct or indirect result of my decision to have a tattoo at this time.
7. I acknowledge infection is always a possible result of permanent make-up application and I agree to follow all suggested instructions concerning the care of the permanent make-up site while it is healing.
8. I acknowledge and give consent to this permanent make-up technician to use images of my tattoo(s) for marketing and/or publishing purposes in various media such as Instagram, Facebook, YouTube, etc.
9. I understand I will have permanent make-up applied using appropriate instruments and sterilization techniques. I understand the permanent make-up site usually takes 2 weeks or longer to heal.
10. I agree to release and forever discharge, and hold harmless to the technician, employees, contractors, and management of the permanent make-up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo decision(s) made consenting to this permanent procedure.
11. I acknowledge that I have not consumed Fish Oil, Vitamin E, or Motrin within the past 7 days, as they are natural blood thinners
12. I acknowledge I have not consumed caffeine within the last 48 hours
13. I acknowledge I have not had Botox or Filler within past 3 weeks

I acknowledge by signing this release, that I have been given the full opportunity to ask all the questions which I might have about obtaining permanent make-up procedure(s) and that all my questions have been answered

Signature