Permanent Makeup Client Information & Consent Form

Name*

First NameLast Name

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

This form is designed to give information needed to make an informed choice of whether or not to undergo a Permanent Makeup application. If you have questions, please don't hesitate to ask.

Although Permanent Makeup is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

Permanent Makeup is the process of inserting pigment into the dermal layer of skin and is a form of tattooing.

All instructions that enter the skin or come in contact with body fluids are sealed and sterilized beore use and disposed of after use. Cross contamination guidelines are strickly adhered to.

Generally, the resulsts are excellent. However, a perfect result is not a realistic expectation and results are not guaranteed. It is usual to expect a touch-up after the healing is completed.

Initally the color will appear much more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 30-40%, soften, and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years.

Photography Release Consent

I would like your permission to use photographs of your before and after permanent make-up application for advertising. Your consent is necessary regarding this.

Please select an option below.

YES, feel free to use the photos.NO, please do not use the photos.

Are you ill or have you ever experienced Covid-19 related symptoms in the past 7 days?*

YesNo

Household or family member who has had Covid-19 symptoms in the past 7 days?*

YesNo

Close contact with anyone who has had Covid-19 in the past 14 days?*

YesNo

18 years or older?*

YesNo

History of MRSA*

YesNo

Abnormal Heart Condition*

YesNo

Alcoholism*

YesNo

Diabetes*

YesNo

Autoimmune disorder*

YesNo

Tumors/Growths/Cysts*

YesNo

Hepatitis A B C D*

YesNo

Easy Bleeding*

YesNo

Pregnant now/Breastfeeding now*

YesNo

Difficulty numbing with dental work*

YesNo

Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.*

YesNo

Allergies to metals*

YesNo

Taking blood thinners such as: Asprin, Ibuprofen, Alcohol, Coumadin, etc.*

YesNo

Please list any medications you are taking:

Any disease or disorders not listed:*

Forehead/Brow Lift*

YesNo

Brow Tinting*

YesNo

Botox*

YesNo

If Yes, date of last Botox treatment:

Facelift*

YesNo

Chemical Peel*

YesNo

If Yes, date of last Chemical Peel:

Oily skin*

YesNo

Tan by booth or salon*

YesNo

Do you use skin care products containing Retin-A, Glycolic Acid, or AlphaHydroxyl?*

YesNo

Accutane or acne treatment*

YesNo

I agree that all of the above information is true and accurate to the best of my knowledge.

Signature

Date Signed

Date

Permanent Makeup Client Information & Consent Form

Consent and Release Agreement for Semi-Permanent Makeup

Client Medical History