PERMANENT MAKEUP CONSENT & CLIENT RECORD

PERMANENT MAKEUP CONSENT & CLIENT RECORD

Required by Florida Department of Health — Tattoo Program Make Me Beauty Studio 6735 Conroy Windermere Rd, Suite 304, Orlando, FL 32835 Phone: 321-464-4321
SECTION 1 — Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
🔷 SECTION 2 — PROCEDURE DETAILS
Date of Procedure

MonthDayYear
Date
SECTION 2 — Procedure Details
PMU area
Description of Procedure(Example: Ombre Brows — soft pixel shading)
SECTION 3 — HEALTH SCREENING QUESTIONS
Are you pregnant or breastfeeding?
Have you consumed alcohol or recreational drugs in the last 24 hours?
Have you taken blood-thinning medication today?
Do you have known allergies to pigments, dyes, anesthetic, or topical products?
Do you have any medical conditions that may be relevant to this procedure, including cancer, ongoing oncology treatment, immune system conditions, bleeding disorders, or any other health concerns?
Have you had recent cosmetic procedures in the treated area (peels, microneedling, laser, fillers)?
If YES, please explain.
🔷 SECTION 4 — CLIENT CONSENT
CLIENT CONSENT

By signing and initialing below, I confirm the following:

I understand that permanent makeup is a form of tattooing. I understand that some discomfort may occur during the procedure. I acknowledge that results vary depending on individual skin type, lifestyle, and aftercare. I understand that the artist cannot guarantee a specific outcome. I confirm that I have not consumed alcohol or recreational drugs within the last 24 hours. I agree to follow all aftercare instructions provided to me both verbally and in writing. I understand that failure to follow aftercare instructions may affect my final healed result. I consent to the storage of my client record for at least two (2) years as required by the Florida Department of Health. I release Make Me Beauty Studio and the performing artist from liability for normal and expected reactions of the tattoo healing process.
Client Initials:
SECTION 5 — AFTERCARE ACKNOWLEDGMENT
AFTERCARE ACKNOWLEDGMENT

I confirm that I have received both written and verbal aftercare instructions for my permanent makeup procedure. I understand it is my responsibility to follow these instructions to support proper healing. I acknowledge that the artist has explained the general healing process and what to expect after the procedure. I understand that failure to follow aftercare instructions may affect retention, color, and overall results.
Client Initials :
SECTION 6 — CLIENT CONSENT ( mental capacity statement)
CLIENT CONSENT

I confirm that I am of sound mind, acting voluntarily, and providing this consent of my own free will.
Client Initials:
SECTION 7 — PHOTO CONSENT
Do you allow the studio to use photos/videos for documentation and promotional purposes?
Client Signature
SECTION 7 — EQUIPMENT & SAFETY LOG
ARTIST INFORMATION
Artist License Number
Needle / Cartridge Type
LOT Number
Expiration Date (if listed)

MonthDayYear
Date
Were all single-use materials disposed of properly?
INTERNAL STUDIO NOTES (Optional) Internal notes (pigments used, color formula, follow-up comments)
Signature PMU artist
Date of procedure

MonthDayYear
Date
Should be Empty:

PERMANENT MAKEUP CONSENT & CLIENT RECORD

SECTION 1 — Client Information

🔷 SECTION 2 — PROCEDURE DETAILS

SECTION 2 — Procedure Details

SECTION 3 — HEALTH SCREENING QUESTIONS

🔷 SECTION 4 — CLIENT CONSENT

SECTION 5 — AFTERCARE ACKNOWLEDGMENT

SECTION 6 — CLIENT CONSENT ( mental capacity statement)

SECTION 7 — PHOTO CONSENT

SECTION 7 — EQUIPMENT & SAFETY LOG