Permanent Makeup Consent Form

Date of birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Color(s)

Please take a moment to answer the following questions

Are you presently taking any medications?

YesNo

Please list*

Are you pregnant?

YesNo

Do you have any allergies to cosmetics, food or drug?

YesNo

Please specify

Please check if you are affected by or have any of the following

I agree with

• I understand the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand there may be a certain amount of pain associated with the procedure and that other adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fading or loss of pigment may occur. Secondary infection in the procedure rarely occurs.

• I absolutely understand and accept the the PMU procedure is a process, sometimes requiring more than one application of color to achieve desirable results.

• I agree to adhere to the post-procedure instructions.

• Depending on the procedure(s) which I select, I accept responsibility for determining the color, shape, and position of the eyebrows, eyeliner, color and/or the color of camouflage.

• I understand the taking of before and after procedure(s) photos are required and may or may not be used for advertising. I have read the above paragraphs, agree that they have been explained to my full understanding, and give my consent for the procedure(s).

Client Signature

Date

Client Name

First NameLast Name