Permanent Makeup Client Information & Consent Form

  • Permanent Makeup Client Information & Consent Form

  • Format: (000) 000-0000.
  • Date of Birth*
     - -

  • Consent and Release Agreement for Semi-Permanent Makeup

  • 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.

  • Client Medical History

    Please check Yes or No to the following:
  • Are you ill or have you ever experienced Covid-19 related symptoms in the past 7 days?*
  • Household or family member who has had Covid-19 symptoms in the past 7 days?*
  • Close contact with anyone who has had Covid-19 in the past 14 days?*
  • 18 years or older?*
  • History of MRSA*
  • Abnormal Heart Condition*
  • Alcoholism*
  • Diabetes*
  • Autoimmune disorder*
  • Tumors/Growths/Cysts*
  • Hepatitis A B C D*
  • Easy Bleeding*
  • Pregnant now/Breastfeeding now*
  • Difficulty numbing with dental work*
  • Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.*
  • Allergies to metals*
  • Taking blood thinners such as: Asprin, Ibuprofen, Alcohol, Coumadin, etc.*
  • Forehead/Brow Lift*
  • Brow Tinting*
  • Botox*
  • Facelift*
  • Chemical Peel*
  • Oily skin*
  • Tan by booth or salon*
  • Do you use skin care products containing Retin-A, Glycolic Acid, or AlphaHydroxyl?*
  • Accutane or acne treatment*

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

  • Date Signed
     - -
  • Should be Empty: