Permanent Makeup Consent + Release Form

Permanent Makeup Consent + Release Form

Celestial Beauty, LLC, 200 N Rehoboth Blvd Suite A, Milford, DE 19963, celestialbeauty.de@gmail.com, 302-362-5611
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Questionnaire

Please answer the following questions honestly. This information is confidential and ensures your safety.
Do you have any of the following medical conditions? (Check all that apply)
If any of the above apply, please list medications or details:
Are you currently taking blood thinners, aspirin, or any medications that affect healing?
Have your consumed alcohol, caffeine, or recreational drugs in the last 24 hours?
Have you had Botox, fillers, or other cosmetic treatments near the area in the last 2 weeks?
Are you currently pregnant or nursing?
Do you have any blood borne pathogens, transmittable diseases, or recent illnesses?
Procedure Details and Risks
Permanent makeup is a form of tattooing where pigment is implanted into the skin. As with any cosmetic procedure, there are potential risks, including but not limited to:
- Allergic reactions
- Infection
- Uneven or faded results
- Swelling, redness, or irritation
- Scar formation
I understand that multiple sessions may be required to achieve desired results and that final results depend on skin type, aftercare, and other factors beyond the artist's control.
Aftercare and Maintenance

I understand the importance of following aftercare instructions provided by my technician to ensure optimal healing and results. Failure to follow these instructions may affect the outcome of the procedure.
Acknowledgments and Consent

By checking below, I acknowledge and consent to the following:
Please check each statement to indicate your understanding:
Photography Consent
State Issued Photo ID

Cancelof
Client Signature

I have read and fully understand this consent and disclosure form. I have been informed of all risks and have had the opportunity to ask questions. By signing below, I agree to proceed with the permanent makeup procedure under the terms outlined above.
Client Name (Printed):

First NameLast Name
Client Signature:
Today's Date

MonthDayYear
Date
Should be Empty:

Permanent Makeup Consent + Release Form

Health Questionnaire

Procedure Details and Risks

Aftercare and Maintenance

Acknowledgments and Consent

Client Signature