BeautyFull by Cynthia Permanent Cosmetics

Permanent Cosmetics & Paramedical Micropigmentation

~Enhancing natural beauty with precision and care~
www.beautyfullbycynthia.com

Phone: 973-433-5933

Email: Beautyfullbycynthia@gmail.com
Client Intake Information
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Services Requested
Which services are you interested in receiving now and/or in the future?*

Powder Brows ($575)3D Areola Restoration ($350–$850, consultation required)Microblading ($550)Scar Camouflage (price based on size, consultation required)Lip Blush ($650)Saline Tattoo Removal (price varies)Eyelash Enhancement Liner ($450)
How did you hear about BeautyFull by Cynthia?*

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Describe your desired outcome
Detailed Medical History
Medical information is confidential and helps determine candidacy for permanent cosmetic or paramedical micropigmentation services. Please answer truthfully.*

Heart conditions / Pacemaker / DefibrillatorSkin disorders (Psoriasis, Eczema, Dermatitis)High or Low Blood PressureHerpes Simplex Virus (Cold sores)Diabetes (Type 1 or Type 2)Active acne or infections in treatment areaBleeding disorders or blood clotting issuesHistory of cancer / Chemotherapy / RadiationKeloid or hypertrophic scarringPregnancy or BreastfeedingSeizures / EpilepsyRecent surgeries (within 12 months)Hepatitis A, B, or CRegular use of blood thinners / aspirin / ibuprofenHIV / AIDSAllergy to lidocaine / epinephrine / pigmentsAutoimmune diseases Lupus, RA, etc
Current Medications
Please list any recent surgeries below
Date of surgery

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Last Botox, filler, or cosmetic treatment (type/date)

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Additional health information your artist should know
General & Informed Consent
General Consent

Consent to treatment, risks and procedures
I acknowledge that I am at least 18 years of age and am voluntarily consenting to receive permanent makeup services at BeautyFull by Cynthia Permanent Cosmetics. I understand that permanent cosmetics & paramedical micropigmentation services are a form of tattooing and that individual results vary based on skin type, lifestyle, and aftercare. No specific outcome is guaranteed.
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Informed Consent
Please review and check every box.*

I have been informed of the procedure steps, risks, benefits, alternatives, and aftercareI understand pigments may fade or shift over time and may require future color boosts or touch-ups.I understand temporary redness, swelling, and discomfort can occur.I have disclosed all medical conditions, medications, and recent procedures truthfully to the bestI accept responsibility for strict adherence to the aftercare instructions provided.I release the technician from liability for complications related to undisclosed conditions or
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Waiver & Hold Harmless
I, the undersigned, agree to release, indemnify, and hold harmless BeautyFull by Cynthia Permanent Cosmetics, its owner, employees, contractors, and assigns from any and all claims, demands, or causes of action arising out of or connected with the PMU procedure, including but not limited to known or unknown injuries, allergic reactions, infections, scarring, or dissatisfaction with aesthetic outcome. I understand that healing is a multi-stage process and that results vary by individual. I acknowledge that no refunds are issued for services rendered.
sessions.*

I understand that cosmetic tattooing is considered semi-permanent and may require maintenanceI understand that if I have a history of keloid scarring, I may not be a candidate for certainI agree to contact my artist and seek appropriate medical care if I experience signs of infection orI consent to the use of topical anesthetics as needed unless I have disclosed an allergy.
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Photography & Video Release
I grant permission to BeautyFull by Cynthia Permanent Cosmetics to capture and use photographs and/or video recordings of my treatment area for documentation, education, portfolio, and marketing (including social media, website, and print Identifying features (eyes/face) may be cropped to protect privacy where appropriate. This consent is voluntary and may be revoked in writing for future use.
YES, I consent to photography/video use as described.
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Client Acknowledgment
I have read and understood all sections of these forms. I have had all questions answered to my satisfaction. I certify that the information provided is complete and accurate. I consent to proceed based on the information above.
Client Name (Printed)
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Office Use Only
Technician Name (Printed): Cynthia L. Awadallah, C.A.A.M.
Service Date

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Service Performed
Notes
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Permanent Cosmetics & Paramedical Micropigmentation

Client Intake Information

Services Requested

Detailed Medical History

General & Informed Consent

General Consent

Informed Consent

Waiver & Hold Harmless

Photography & Video Release

Client Acknowledgment

Office Use Only