Consent Form

Consent Form

Permanent Make Up Application
I acknowledge by signing this release that I have been given the full opportunity
to ask any and all questions which I might have about obtaining permanent
make-up from:
Signature

Powered by Jotform SignClear
(hereafter called “technician”) and that all of my questions have been answered
to my full and total satisfaction.
P R O C E D U R E T O B E P E R F O R M E D : ( P L E A S E C H O O S E )

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

Initials at each line -
I acknowledge that obtaining permanent make-up is my choice alone. Theapplication of permanent make-up will result in a permanent change to myappearance, and that needles and inks will go into my skin. Norepresentations have been made to me as to the original condition, and it isvery costly to remove.
I am not pregnant or nursing. I do not have any history of herpes infectionat the proposed procedure site. I do not have epilepsy, diabetes, allergicreaction to latex or antibiotics, hemophilia or other bleeding disorders. I donot have cardiac valve disease or suffer from any heart conditions ormedications that thins my blood.
If I suffer from hepatitis, or other risk factors for blood borne pathogenexposure, or any other communicable disease, I have informed theTechnician of the fact and have been advised of any medications andprocedure necessary to promote the satisfactory healing of my tattoo.
I do not suffer from any medical or skin condition(s) such as, but not limitedto : Keloid or hypertrophic scarring, psoriasis at the site of the permanentmake-up, or any open wounds or lesions at the site of the tattoo.
I do not have a history of medications use or currently using medication,including being prescribed antibiotics prior to dental or surgical procedures.
I have advised the Technician of any allergies to latex gloves, ormedications. I acknowledge that such a reaction is possible.
I have truthfully represented to the technician that I am 18 years of age orolder. I am not under the influence of any drugs or alcohol. To myknowledge, I do not have any physical, mental, or medical impairment ordisability that might affect my well being as a direct or indirect result of mydecision to have a tattoo at this time.
I acknowledge infection is always possible as a result of permanent makeup application, and i agree to follow all suggested instructions concerningthe care of the permanent make-up site while it is healing.
I acknowledge and give consent to this permanent studio to use images(before and after) of my tattoos(s) for marketing and, or publishingpurposes in various media such as the internet, magazine, printed, andor television etc.
I understand I will have permanent make-up applied using appropriateinstruments and sterilization techniques. I understand that thepermanent make-up site usually takes 2 weeks or longer to heal. I agreeto release and forever discharge, and hold harmless, the technician, allemployees, contractors and the management of the permanent makeup studio from any and all claims of negligence, damages, or legalactions arising from or connected in any way with my tattoo, theprocedure, and conduct used in my tattoo and assume all responsibilityfor the decision(s) made consenting to this permanent procedure.
I am aware that permanent cosmetic inks, dyes, and pigments have notbeen approved by the federal Food and Drug Administration and thatthe health consequences of using these products are unknown.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Age
DOB
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies?

YesNo
Please List:
Sensitive Skin

YesNo
Explain:
Signature

Powered by Jotform SignClear
Technician Info Only
Equidment Used :
Lot Or Model Number :
Should be Empty:

Consent Form

Technician Info Only