PERMANENT MAKEUP FORM

Permanent Makeup Consent Form

First name

Last name

Email

Phone

Birthday

Career

Referral

Address

VAT ID

File upload

Emergency Contact

Phone

Health and Medical History:

(To ensure your safety, please answer the following questions.)

Are you pregnant or breastfeeding?

Yes

No

Do you have any allergies (e.g., latex, pigments, anesthetics)?

Yes

No

If yes, please list:

Do you have a history of cold sores or fever blisters?

Yes

No

Are you currently taking any medications, including blood thinners, antibiotics, or fish oil?

Yes

No

If yes, please list:

Do you have a history of skin sensitivities or skin disorders (e.g., eczema, psoriasis, rosacea, lupus)?

Yes

No

Do you have any of the following medical conditions?

Heart Problems

Yes

No

Diabetes

Yes

No

Hemophilia

Yes

No

Autoimmune disorders

Yes

No

HIV/AIDS

Yes

No

Hepatitis

Yes

No

Epilepsy

Yes

No

Have you consumed alcohol or tetrahydrocannabinol (THC) in the past 24 hours?

Yes

No

Have you consumed aspirin, ibuprofen, allergy medicine or fish oil in the past 24 hours?

Yes

No

Procedure Information:

Type of Procedure (Check all that apply):

Potential Risks & Contraindications:

I understand that I am receiving a permanent cosmetic tattoo and that results may vary depending on skin type, lifestyle, and adherence to aftercare instructions.

I understand that achieving optimal results may require multiple sessions. Permanent makeup typically involves a minimum of 2 sessions, with the initial session followed by a touch-up approximately 4 weeks later.

I understand that permanent makeup or cosmetic tattooing may cause minor discomfort but is not completely painless.

I understand that the only way to completely remove permanent makeup is through laser tattoo removal, which is not offered by Posh Permanent Makeup LLC.

I understand that permanent makeup is a service that typically requires annual touch-ups to maintain its appearance.

I understand that the following risks are associated with permanent makeup tattoo procedures:

Infection: Though rare, infection can occur if aftercare instructions are not followed.
Allergic Reactions: While uncommon, allergic reactions to pigments or topical anesthetics can occur.
Scarring: Improper healing or failure to follow aftercare could lead to scarring.
Fading: Tattoo pigments can fade over time, especially with exposure to the sun or certain skin treatments (e.g., chemical peels, laser treatments).
Color Changes: Pigments may alter in appearance based on skin type and healing process.

Aftercare Instructions:

I understand that aftercare is essential to the healing process and must be followed to avoid complications and ensure the best results. Instructions include but are not limited to:

Avoid touching the area unnecessarily.
No swimming, hot tubs, or direct water exposure for at least 2 weeks.
Avoid excessive sweating or exercise for 7-10 days.
No facials, chemical peels, or other treatments for 2-4 weeks.
Apply any recommended ointments as directed.
No makeup application on the treated area during healing.

Consent and Waiver:

Client Certification:

By signing below, I certify that all the information provided is accurate and complete to the best of my knowledge. I have read and understand the above information and give my consent for the procedure.

Date and time

:

Signature