Client Consent Form

Please read and select "I agree" on each of the statements below:

I certify I am over the age of 18.

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 permanent makeup for brow, eyes, or lips.

I have been informed of the nature, risks, and possible complications, and consequences of permanent makeup. I understand the permanent cosmetic procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: temporary minor bleeding, bruising of skin surfaces, swelling, redness, temporary discoloration, infection, scarring, inconsistent color, and spreading, fanning or fading of pigments.

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.

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

I understand that successful color 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 hyper-pigmentation.

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

I understand that successful color 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 hyper-pigmentation.

I understand that any 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.

I agree to forego a patch test and accept the risk that a reaction is possible.

During the treatment, despite all the precautionary measures made by the Practitioner, injury is possible. I will not hold the Practitioner performing this service on me responsible for any issues that may arise because of having the procedure performed on me.

I understand that there are risks associated with Permanent Makeup, if any sort of reaction occurs I will seek medical attention and inform my Practitioner.

I understand that the color/outcome may not turn out as desired due to the undertone and health of my skin, and that individual results will vary on each individual.

It is my responsibility to advise the Technician of any concerns I may have before the procedure.

I understand and agree to the aftercare instructions provided by my Technician. By not following the aftercare instructions, I am aware that the desired results may not be achieved.

I understand the permanence of this procedure and my skin will be pigmented with iron oxides that may never fade completely.

I acknowledge and accept that no guarantees regarding the outcome of the procedure.

The Technician performing the procedure will not be held liable for any damages caused to me or my skin by any reason, including allergic reaction, skin sensitivity, and failure to follow the aftercare instructions.

I have declared all relevant history, and if any changes occur in the future I will notify my Technician.

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure. I consent to the permanent makeup procedure being performed on me and accept that I understand the risks and complications involved.

I understand that any 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.

I certify that I am not under the influence of drugs or alcohol, I am not pregnant or nursing, and I consent to have the micro-pigmentation or permanent cosmetic procedure listed above performed today. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.

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

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

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 technician may apply topical anesthetics to alleviate discomfort. I understand there is a small chance of an allergic reaction to topical anesthetics.

I understand that my technician only utilizes sterilized, disposable equipment to minimize the risk of infection or contamination and that my technician has received training in inappropriate sanitation and hygiene techniques prior to performing any procedures. While the risk of infection from our procedures is minimal, the possibility of such an occurrence cannot be totally prevented. Accordingly, I understand and accept the risk and release my technician and the spa from any and all liability related to the subject procedure, except instances involving gross negligence.

If I have any signs or symptoms of infections I will seek medical care. Signs of infection include but are not limited to redness, swelling, tenderness of the procedure site, a red streak going from the procedure site towards the heart, elevated temperature, or drainage from the procedure site.

I acknowledge that this procedure may alter my appearance and that no representations have been made to me as to remove my permanent makeup.

I understand that tattoos may cause Magnetic Resonance Imaging (MRI) artifacts and that there may be a warming and/or tingling sensation in the areas where I received the permanent cosmetic procedure during the MRI due to the iron oxide properties of some pigments. I understand that I should advise my physician that I have permanent makeup (a tattoo) in the event I am in need of an MRI.

I understand that tattoo inks, dyes, and pigments have not been approved by the Food and Drug Administration (FDA) and that the health consequences of using these products are unknown.

I hereby give permission for any photos, videos, or audio that are taken of me to be used in and/or for any lawful promotional materials, such as but not limited to newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media pages, and other print and digital communications. This authorization shall continue indefinitely and extends to all languages, media, formats, and markets now known or later discovered.I renounce all claims I may have to royalties or other forms of payment resulting from or connected to the use of the image or sound recording. All claims that I, my heirs, representatives, executors, administrators, or any other person acting on my behalf or on behalf of my estate may hold harmless and release them from any claims that they may bring. I hereby acknowledge that I have completely read and fully understand the above release agreement.

Birth Date

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Name

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Signature

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PMU - New Client Consent Form