Full Name
Date of Birth
Address
City
State
Zip Code
Phone*
Email
How Did You Ffind About Us
I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions about obtaining permanent makeup from:
X.
(hereafter called "Technician") and that all of my questions have been answered to my full satisfaction.
PROCEDURE TO BE PERFORMED:(PLEASE CHOOSE ONE OR MORE) :
Ombre powder browBrow correctionMicrobladingLip blushDark Lip NeutralizationEyelinerScalp Micro PigmentationSkin CamouflageCombo Brows
I SPECIFICALLY ACKNOWLEDGE AND AGREE AS FOLLOWS: ANSWER YES OR NO AT EACH LINE-
I acknowledge that obtaining permanent makeup is my choice alone. The application of permanent makeup will result in a permanent change to my appearance, and needles and inks will be applied to my skin. No representations have been made to me about the original condition, and removal is very costly..
I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, an allergic reaction to latex or antibiotics, hemophilia, or other bleeding disorders. I do not have cardiac valve disease or any heart conditions, or use medications that thin my blood.
If I suffer from hepatitis, other risk factors for blood-borne pathogen exposure, or any communicable disease, I have informed the Technician and have been advised on any necessary medications and procedures for satisfactory healing.
I do not suffer from any medical or skin conditions such as, but not limited to, keloid or hypertrophic scarring.
I do not have a history of medication use or currently use any medication, including antibiotics prescribed for dental or surgical procedures.
I have informed the Technician of any allergies to latex gloves or medications and acknowledge that such a reaction is possible.
I truthfully represent that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have a tattoo at this time.
I acknowledge infection is always possible as a result of permanent make- up application, and I agree to follow all aftercare instructions concerning the care of the permanent makeup site while it is healing. I agree that the technician went over the aftercare instructions with me and has also given me written aftercare instructions.
I consent to the permanent studio using images (before and after) of my tattoos for marketing and publishing purposes in various media, such as the internet, magazines, and television.
I understand I will have permanent make-up applied using appropriate instruments and sterilization techniques understand that the permanent make-up site usually takes 2 weeks or longer to heal and agrees to release and forever discharge and hold harmless, the technician, all employees, contractors and the of the permanent make up a studio from any and all claims of neglect damages, or legal actions arising from or connected tattoo, the procedure, and conduct used in my tattoo and assume responsibility for the decision(s) made consenting to this permanent procedure.
I understand that permanent cosmetic inks, dyes, and pigments have not been approved by the federal Food and Drug Administration, and the health consequences of using these products are unknown.
I have been advised that if I have oily skin, I may need 1-2 extra touch-ups, as skin with more oil requires more follow-ups.
Do you have any allergies to medication?
YesNo
Are you currently taking any medication?
Do you have any thyroid problems or complications?
Do you bruise easily or frequently?
Are you taking recreational drugs?
Do you have eczema (atopic dermatitis)?
Are you allergic to latex or powder in gloves?
Do you have epilepsy or seizures?
For your safety and to provide the best care, please let us know if you have any of the following conditions:
Do you have HIV or AIDS?
Do you have keloid scarring (scar tissue overgrowth)?
(Lip Blush Only)Do you have a history of cold sores?
If yes, you must take Valtrex 3 days before and 3 days after your procedure. Please describe:
Do you have Botox fillers?
If yes, you must wait 10 days from the date of injection before lip blushing. Please describe
Do you have diabetes, lupus, or any autoimmune disorder?
Are you undergoing chemotherapy or radiation treatment?
Are you allergic to novocaine or any other local anesthetics?
I Request the following PMU procedures (Please Tap)
EyelinerEyebrowsLipsSMPSkin CamouflageCombo Brows
I Request the following touch up procedures (Please Tap)
Procedure Cost (as discussed):
Touch-up Procedure Cost:
Date Date
Note: Please add your email address. We reserve the right to refuse service. Cancellations or refunds are not allowed for any reason. A $50 consultation fee will apply for all complimentary consultations. A refund will be given only if you decide not to proceed with our services on the day of the consultation. Otherwise, the consultation fee will be applied to the service. If a potential customer does not show up for the consultation, no refund will be given. A 3% processing fee will be applied if paying by credit card.
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