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
BrowsEyelelinerLipsColor RefreshOther
Description of Procedure(Example: Ombre Brows — soft pixel shading)*
SECTION 3 — HEALTH SCREENING QUESTIONS
yesno
yesno
yesno
yesno
yesno
yesno
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
yesno
Client Signature*

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SECTION 7 — EQUIPMENT & SAFETY LOG
ARTIST INFORMATION*
Artist License Number*
Needle / Cartridge Type*
LOT Number*
Expiration Date (if listed)

MonthDayYear
Date
YesNo
INTERNAL STUDIO NOTES (Optional) Internal notes (pigments used, color formula, follow-up comments)
Signature PMU artist*

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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