Permanent Makeup Consent Form

Permanent Makeup Consent Form
Name
First NameLast Name
Phone Number
Area CodePhone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
Date
Cosmetic Procedure
Patch Test Process
CONSENT
I declare that I am of legal age, and not under the influence of alcohol or any drug, neither I am pregnant, nor nursing an infant, at the time I have submitted this consent.
The nature, risks, complications, and consequences of the procedure has been explained to me in a well and understanding manner. I understand that permanent make up procedures are not an exact science but an art, and therefore there is no full guarantee that the desired outcome shall be fully achieved.
I have been advised of a patch test for possibility to allergic reaction to pigments and medications. I {patchTest} in the said patch test. I release the institution from any liability should I develop any allergic reactions from the pigment in case of a waiver.
I acknowledge that in case of any other skin treatments, laser hair removal, plastic surgery, or other treatments or procedures made to the affected area, such may result in adverse changes to my permanent cosmetics and may not be fixed.
I certify that I have read and affirm the abovementioned statements and was explained to me to the best understanding of this consent and the procedures to be taken.
Signature
Clear
Date Signed
MonthDayYear
Date
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