Permanent Makeup Client Intake Form

Permanent Makeup Client Intake Form
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Client Information
Full Name

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Email
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Consent & Release Form for Permanent Makeup Procedures
I (Kaytlynn Aviles) make no attempt to, nor claim to, practice medicine. Some individuals may experience complications related to permanent makeup applications. These complications are usually mild and resolve within a few days; however, more serious complications are always a possibility. If you are in good health and there are no visible contraindications to receiving a tattoo, you must approve the procedure and color prior to application.
Authorization
I confirm that all information given in this form is true, complete, and accurate. I release Brow Queen and the brow technician from any responsibility in the case of accident, illness, or injury. I understand that pigment will fade over time and may change due to metabolism, skin type, medication, age, smoking, alcohol, sun exposure, and use of products containing Retin-A or glycolic acids.

I understand this is not a one-step process and may require subsequent visits to achieve the desired result. I acknowledge that the initial fee includes the first visit only and does not cover the touch-up visit within two months of the initial appointment. I understand that the outcome is a permanentchange.

I fully understand the nature of the procedure and acknowledge possible complications, reactions, or adverse effects due to the pigments applied. I acknowledge that this is a tattooing process, and I have disclosed any relevant medical conditions. I understand that no guarantees have been made regarding the outcome.

I have reviewed the pre-care and after-care instructions and agree to strictly follow them. I understand that before and after photos may be taken and give permission for Kaytlynn Aviles, owner of Brow Queen (@Brow_Queen), to use them for marketing or promotional purposes.

I acknowledge that I have had the opportunity to ask any and all questions regarding the procedure, and that those questions have been answered to my complete satisfaction. I understand and agree to all of the above.
Waiver, Release of Liability, and Indemnity
I authorize Kaytlynn Aviles of Brow Queen to perform the permanent application of pigment (tattoo) to my skin. I have been fully informed of the procedure, methods, and possible results. In consideration of this service, I hereby release and agree not to file any claim or legal action against Kaytlynn Aviles or Brow Queen for damages, compensation, loss, or any other relief related to this procedure.

This agreement will serve as a legal waiver and estoppel in the event of any future claims. I confirm again that all information I have provided is true and accurate. I release Kaytlynn Aviles Aka Brow Queen from any responsibility for accidents, illness, or injury related to the procedure.

I acknowledge that the pigment may fade and change over time for various reasons, and that this is a multi-step process. I accept that the initial fee covers the first appointment only and does not include follow-ups or touch-ups. I fully understand the nature of this tattooing procedure and the potential risks, including allergic reactions or other complications.

I have disclosed all medical conditions and understand that no assurances were given about the final results. I agree to follow all after-care instructions and allow photos to be taken for documentation and marketing use by Kaytlynn Aviles.

By signing below, I acknowledge that I have had every opportunity to ask questions and have received satisfactory answers. I accept full responsibility for the outcome of this procedure.

I further release Kaytlynn Aviles and Brow Queen from any responsibility for pre-existing conditions I failed to disclose or any consequences arising from those conditions. I understand I am solely responsible for any medical treatment I may require as a result of undergoing this procedure.

Having read and understood everything stated above, I hereby consent to the procedures as outlined, accept full responsibility for the results, and hold harmless Kaytlynn Aviles and Brow Queen from any and all liability.
Date

MonthDayYear
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Client Signature
Kaytlynn Aviles

222 E Main st Barstow Ca 92311

(760) 669-7595

BrowQueenK@yahoo.com
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Permanent Makeup Client Intake Form

Client Information

Medical History

Consent & Release Form for Permanent Makeup Procedures

Authorization

Waiver, Release of Liability, and Indemnity