Semi-Permanent Makeup Consent Form
Please complete this form before your procedure to provide your health information and consent.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Procedure Details
Procedure Type
*
Please Select
Microblading
Lip Blush
Eyeliner
Ombre Brows
Other
Technician Name
*
Procedure Date
*
-
Month
-
Day
Year
Date
Medical & Health Information
Do you have any allergies?
*
Yes
No
If yes, please specify
Do you have any skin conditions?
*
Yes
No
If yes, please describe
Do you have diabetes?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
History of keloid scarring?
*
Yes
No
Are you taking blood thinners or other medications?
*
Yes
No
Any other medical conditions
Acknowledgment & Consent
Final Section
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: