Permanent Makeup Consent Form

Permanent Makeup Consent Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Do you allow us to leave voicemails on the number given above?*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cosmetic Procedure*
Date of Appointment*

MonthDayYear
Date
Are you Pregnant or Nursing?*
Are you currently under the care of a physician? please explain, if no write NA *
Physicians Name

First NameLast Name
Physicians Phone Number
Please list all medications you are PRESENTLY Taking, if none write NA *
Are you planning Cosmetic Surgery? If so, what and when? If no, write NA*
Please list all medications you have taken in the PAST 6 Months and NO LONGER are taking, if none write NA*

Are you willing to Patch Test prior to proceedure*
Emergency Contact*

First NameLast Name
Emergency Contact Phone number*
CONSENT

I declare that I am of legal age, and not under the influence of alcohol or any drug, neither I am pregnant, nor nursing an infant, at the time I have submitted this consent.

The nature, risks, complications, and consequences of the procedure has been explained to me in a well and understanding manner. I understand that permanent make up procedures are not an exact science but an art, and therefore there is no full guarantee that the desired outcome shall be fully achieved.

I have been advised of a patch test for possibility to allergic reaction to pigments and medications. I release the institution from any liability should I develop any allergic reactions from the pigment in case of a waiver.

I acknowledge that in case of any other skin treatments, laser hair removal, plastic surgery, or other treatments or procedures made to the affected area, such may result in adverse changes to my permanent cosmetics and may not be fixed.

I certify that I have read and affirm the above mentioned statements and was explained to me to the best understanding of this consent and the procedures to be taken.
Signature*

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Date Signed*

MonthDayYear
Date

INFORMED CONSENT TO PROCEEDURE

I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed.

I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them.

Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color.

I understand that the color selection and color results in all procedures are not an exact science.

I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox, or Restalyne, and I assume this responsibility.

I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics.

If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.

I understand that this procedure will fade and this fading can alter the original pigment color and that this determines that it is a time for a touch-up visit.

I realize this is an elective cosmetic procedure and is not medically necessary.

It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment.

I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up.

I, the undersigned, hereby give my consent to Versa PMU LLC to take and use photographs and videos of me before, during, and after my PMU procedure for marketing purposes on all platforms, including social media, websites, and other promotional materials.

I understand that all skin types are different and results may vary. I release Versa PMU LLC from any and all liability and legal action related to the procedure and its outcomes. Versa PMU LLC reserves the right to cancel or discontinue the procedure at any time and for any reason deemed appropriate. This may include, but is not limited to, concerns about the client's suitability for the procedure, health and safety considerations, or any behavior that the artist deems inappropriate or disruptive.

I give my consent to Versa PMU LLC to confer with my physicians for medical information required for the safety of my procedures.

I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results
to my practitioner.

I am aware that if an infection occurs after I have received Permanent Cosmetics to see with my primary physician or an emergency room immediately.

ACCEPTANCE:

I have read and understand these risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and my questions have been answered.
Signature*

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Date Signed*

MonthDayYear
Date

Cancelation Policy

Thank you for choosing Versa Aesthetics & PMU for your upcoming service. To secure your appointment, we require a credit card on file. Please read and complete the authorization form below.

I, the undersigned, authorize Versa Aesthetics and PMU to charge my credit card in the amount of $50. This fee is to hold my appointment and will be applied as a credit towards my total service cost.

I understand and agree to the following terms:

1. The $50 will be credited towards the total cost of my service.
2. If I fail to provide at least 24 hours notice of cancellation, my card will be charged $50 as a cancellation fee.
3. This authorization is valid for the date of my scheduled appointment.

By signing below, I acknowledge that I have read, understand, and agree to the terms stated above.

Thank you for your cooperation and understanding.
Please provide image of FRONT of card*

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Please provide image of BACK of card*

Cancelof
Signature*

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Versa Aesthetics and PMU

12 Lower Center Street Clinton NJ 08809
P:908-503-5733
E:Versafyme@gmail.com
W:www.versafyme.com
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