Permanent Makeup Consent Form

Permanent Makeup Consent Form
This form seeks to get your consent to use your photos/videos are taken by our company through our artist.

Signing this form gives us the permission to use your photos/videos for the purposes of social media.

The refusal of this form by you will not affect the care you receive in any way.
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Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Age blanks
Gender

MaleFemaleNBOther
Please select the ones you agree;

I grant my full permission to take my photos/videos by your company “before” and “after” of the operation.I give my permission to use, re-use, publish my taken photos/videos in portfolios, advertising, publicity, trade, sale. I won’t demand any charge, royalty or any monetary compensation.I give your company the right to use my name regarding these purposes.
Date

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Date
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Possible risks, hazards or complications:
Pain: Discomfort may occur even after using a topical anesthetic. For instance, pain may be heightened if you are on your menstrual cycle or have consumed caffeine.

Infections: Infections is very unusual. The areas must be kept clean and tretated as open wounds. See “Aftercare instruction card” for more details.

Uneven pigmentation: This can be result from poor healing, infection, bleeding, or many other causes. Your follow up appointment will correct uneven apparance.

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 uneveness.

Excessive swelling or bruising: Some people bruise and swell more than others. Ice packs may help and they will typically disappears with 1-3 days.

Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform your technician now.

Fever blisters: If you are prone to cold sores or fever blisters (herpes simplex). There is a high probability that you will get them. It is advised that you call your doctor for a prescription antiviral to help prevent this form occurring.

Allergic reaction: There is a small posibility of an allergic reaction. You may take a 5-7 days patch test to determine this. Please intitial to:
Waiveblanks or take blank.
I have read and understand very well:
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Date

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Date

You must read and fill out this form completely, making certain that you understand everything and type/write your initials before each one, to indicate you understand them completely

As a client, it is your responsibility to inform the technician of all possible concerns before they begin your procedure.
blanks I am not pregnant/nursing (not elegible if you are)
blanksI will follow the aftercare instructions given to me
blanksI understand permanent makeup is a form to tattoo that requires implantation of pigment in to the skin.
blanks I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.
blanks I am not under the influence of alcohol or drugs or any other substances, legal, or otherwise or consumed alcohol within 24 hours.
blanks I understand it is my responsibility to advise my technician of any concerns I have before the procedure.
blanks l understand the final result depends on how i follow the aftercare, skin type, lifestyle, and coming for touch ups.
blanks I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and will need to mantain the color with future applications and touch up session within 4-8 weeks.
blanksI will tell a skin care professionals or medical personnel about my permanent makeup procedures specially if I am scheduled for an “MRI” (tattooed skin can swell or burn if you get an MRI)
blanksI understand some permanent makeup pigment can only be removed with a surgical procedure.
blanksI understand there is a no refund policy and no guarantee has been made as a result of this procedure.
blanksI accept full responsibility for the decision to have this permanent makeup (Cosmetic tattoo) work done.

Permanent Makeup Consent Form

Possible risks, hazards or complications:

I have read and understand very well:

You must read and fill out this form completely, making certain that you understand everything and type/write your initials before each one, to indicate you understand them completely

Medical history: