Permanent Makeup Client Information Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Date of Birth

Date

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you learn about us?

Please answer the following question with full honesty and accuracy.

Are you taking any kind of medications within the last 6 months?

YesNo

Is it a prescribed medications?

YesNo

Please indicate the medications that you're currently taking

Do you have any known allergies to food, medicine, or cosmetic products?

YesNo

If yes, what are your allergies?

Are you pregnant?

YesNo

Please read all the sentences and sign the agreement.

I authorized ABC Care to perform a cosmetic enhancement upon me on this day.
I was informed that permanent and semi-permanent cosmetic enhancement is the same as the process of tattoo and it is an advanced version of it.
I completely understand that in some rare cases, allergic reactions may occur even after my disclosure of all known allergy history I may have due to the pigment. I accept all the responsibility, and I fully understand the health risk of it.
I accept that the pigment might fade before or after 3 years, and may leave a mark or residue of color.
I understand the possible side effects of the procedure and will be able to diagnose if it is normal or not.
I confirm that I do not have any physical, medical, and mental conditions that might get conflict with the procedure.
I confirm that I will strictly follow the pre and post-procedure instructions given to me.
I confirm that all information I entered in this form is accurate and true to the best of my knowledge.
I hereby certify and give this clinic my full consent to perform the necessary procedure. By signing below, I confirm that I have read and understood the statements above.

Signature

Date Signed

Date

Consent