Permanent Makeup Consent Form

Permanent Makeup Consent
Patient Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Medical / History Data
Do you have any of the following conditions?

HypertensionHeart issuesRashesDiabetesProblems healing woundsIssues blood Clooting or history of hempheliaHistory of keloid scarringHistory of cold sores or fever blistersHistory of anemiaSeizureSpinal Cord IssuesHistory of skin disease or skin sensitivity
Are you wearing any eye contact lenses?*

YesNo
Are you pregnant, breastfeed, or nursing? (Female)*

YesNo
Are you under the age of 18? yes or no*
Have you had botox in your forehead within 4 weeks of the appointment date?
Are you currently taking any medications? If yes, please list them below:
Technicians make no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent make-up applications. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible reasons for restricting you from receiving a tattoo, you must approve of the procedure and the color before the application of your permanent make-up.
Authorization
- I confirm that all information given in this form is true, complete, and accurate.
- I released this organization for any responsibility in case of accident, illness, or injury.
- I understand that with time the pigment can fade and will change according to metabolism, skin type, medication, age, smoking, alcohol, sun exposure, Retin-A and Glycolic acids.
- I understand that the process used to apply color is not a one step process and may require subsequent visits to achieve desired results. I further understand that the fee includes my first visit and one touch-up visit within two months of first appointment and the result of the procedure will be a permanent change
- I understand the nature of the procedure and possible complications, reactions or adverse effects that may occur as a result of the applied pigments. I fully understand this is a tattooing process, and have discussed any medical conditions
- I acknowledge that no assurance was offered about the outcome.
- I have read through the Frequently Asked Questions on the MicroBeauty website and agree to strictly adhere to such instructions.
- I understand that taking before and after pictures may be required and allow MicroBeauty Studio to use the photos for marketing or promotional services.
- I acknowledge by signing below, that I have been given the full opportunity to ask any and all questions which I might have about obtaining this procedure(s) from, Mariah Feser. I also acknowledge that all of my questions have been answered below to my full and total satisfaction. I specifically acknowledge that I have been advised of the fact and matters set below, and I agree as follows.
I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Mariah Feser shall perform permanent application of dyes to the skin of the releaser. Whereas releaser has been informed as to the methods and procedures concerning the result of such treatments, a scratch test will aslso be performed prior to the procedure, if requested by the client, to detect any signs of allergies. I hereby release, acquit and discharge Mariah Feser and any and all persons which are or might be claimed to be liable to me from all claims and demans or whatever nature, actions and causes of action, damages, cost, loss of service, expenses and compensation on account or in any way growing out of personal injuries and property damage to result at any time in the future, whether or not they are in contemplation of parties at the present time and whether or not they arise following the execution of the release as the as the result of treatment procedure rendered. Releaser agrees to indemnify the hold harmless of Mariah Feser for any loss, damage, claim, injury, or expense asserted against myself.
Signature of the Patient*

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Permanent Makeup Consent

Medical / History Data

Authorization