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Permanent Makeup Consent Form

Informed Consent & Medical History Release Form

First name*

Last name*

Email*

Phone*

Date of Birth*

Día

Mes

Año

How did you hear about us?

What procedure(s) are you having done today?

You have the right to be informed so that you may make the decision whether or not to undergo the procedure(s) after knowing the risks and hazards involved. This disclosure is not meant to frighten you, it is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure. Please read the statement below and write initials before each one, to indicate you understand them completely. As a client, it is your responsibility to inform the Technician of all possible concerns before they begin your procedure.

I am the person on the legal ID I have presented as proof that I am at least 18 years of age.*

I am not under the influence of alcohol or drugs or any other substances, legal or otherwise.*

I have been informed that I will get a free touch up within 4 to 6 weeks after the procedure and if I fail to come back within that time frame I will have to pay $50 for my touch up.*

I understand that We have a 24 hour cancellation policy and I must cancel or change 24 hours prior to my appointment. If I fail to do so or if I no-show on my touch-up appointment day I will have to pay $50 for my touch up.*

I understand that it is my responsibility to inform my technician of any problems that I (or my doctor) think could occur for any reason (including but not limited to: allergies, illnesses, medications- including aspirin and/or other medications.*

I understand that after my free 4 to 6 weeks touch up, that in order to maintain my procedure, I may have to come back for further touch ups for which I will have to pay for each touch up I receive. *

I understand there may be risks and hazards related to the performance of this procedure, including but not limited to: allergic reaction to the pigment and/or other products that will be used, lightheadedness, bleeding, bruising, swelling, scarring.*

No warranty or guarantee has been made to me as a result of this permanent makeup/ camouflage/correction procedure, and although my technician will do their best to make sure I am happy with the result, the final result cannot be guaranteed. *

Tattooing is considered permanent, however, it will fade with time and therefore requires touch ups.*

I understand some permanent makeup pigment can only be removed with a surgical procedure, and any effective removal may leave permanent scarring or disfigurement. *

I fully understand the questions, terms, and conditions of this Informed Consent, Medical History and Release Agreement, and all questions have been answered for me.*

I understand that tattoo inks/dyes/pigments have not been approved by the Federal Food and Drug (FDA), and that the Health consequences of using these products are unknown.*

CONFIDENTIAL MEDICAL HISTORY

Are you pregnant?*

NO

YES

Are you breastfeeding?*

NO

YES

Have you had Botox/Dysport or any fillers in the last two weeks*

NO

YES

Are you currently using, or have you used any products containing Retin-A or Hyaluronic Acid (or similar ingredient)?*

NO

YES

Do you use any medications that might affect the healing of the procedure you wish to receive?*

NO

YES

If Yes, Please list all medications you are taking:

Are you allergic to Latex? *

NO

YES

List all other allergies here (including Antibiotics):

Check any conditions listed that apply to you:

Diabetes

Epilepsy

Asthma

Fainting/ Dizziness

Heart Condition

Hemophilia

Blood Thinners

Herpes

T.B.

Eczema/Psoriasis/Other Skin Conditions

Scarring/Keloiding

List all other medical issues/illnesses here:

information I have provided above is complete and true to the best of my knowledge.

Client's Signature*

Firma en la casilla o usa el teclado para escribir.

El campo de firma está vacío.

Today's Date*

Día

Mes

Año

Informed Consent & Medical History Release Form

I, *

certify that this Informed Consent, Medical History and Release Agreement was completed by me and that all entries in it and information are true and complete to the best of my knowledge. I also certify that I have been fully informed of the risks of tattooing/permanent makeup application, including but not limited to: infection, scarring, difficulties in detecting melanoma, and allergic reactions to permanent makeup/tattoo pigment, latex gloves, and other products used. Having been informed of the potential risks associated with getting the permanent makeup/tattoo, I still wish to proceed with application and I assume any and all risks that may arise from the procedure. I also certify that I take full responsibility and waive any claims against VVS Permanent Beauty Inc. and/or my Technician to the fullest extent permitted by law from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which resultor arise from the application/implantation of permanent makeup pigment for eyeliner, eyebrows, lips, re-coloration, camouflage or otherwise, whether caused by the negligence or fault of either the Technician, or otherwise.

Client's Signature*

Firma en la casilla o usa el teclado para escribir.

El campo de firma está vacío.

Sign Here

Today's Date*

Día

Mes

Año

INFORMARSE

Galería de fotos

NUESTROS SERVICIOS

Tratamientos faciales y cuidado de la piel

Tratamiento con plasma de fibroblastos

Maquillaje permanente

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