←

Permanent Makeup

Let us do this part

Today's Date:

Fri Aug 15 2025 10:27

Practitioner:*

Please read and answer

Flu like symptoms *

If you have a fever, flu-like symptoms, shortness of breath, or cough please notify a staff member immediately.

Bloodborne Pathogens*

Do you have any bloodborne pathogens, transmittable diseases or recent illnesses? (it's okay if you do, we just want to know so we can take the necessary safety precautions to protect our staff and others)

Details:

Eaten*

Have you eaten in the past four hours? if not, please let your artist know.

Previous PMU*

Have you had any permanent makeup services done before?

Details:

Goal*

What would you like to achieve with your permanent makeup?

Prescriptions*

Please list any prescription(s) you are taking

Allergies *

Do you have any known allergies?

Details:

Retinoic Acids*

Do you use any Retinoic acids (Rx form of vitamin A including Retin-A, Diferin, Adapalene, Renova, Tazorac, etc.) or Glycolic acids regularly on face or neck?

Details:

Tanning *

Do you tan? Natural sun, tanning beds or tanning sprays?

Details:

Sun exposure*

I understand that sun, tanning beds, pools, anti-aging skin care products, etc. And other medications can affect my permanent makeup.

Cold sores *

Have you ever in your life experienced a cold sore, fever blister, sun blister, or herpes simplex?

Details:

Contacts *

Do you wear contact lenses?

Medical conditions *

Do you have any medical conditions that could negatively affect your procedure? Please inform your artist of any and all medical conditions you’ve had or have that could affect the permanent makeup procedure.

Details:

Discomfort*

I understand that a certain amount of discomfort is associated with this procedure and that minor or temporary swelling, redness, or tenderness may be experienced.

Design Responsibility *

I accept the responsibility for explaining to my artist my desired color, shape, position, and location of pigment for any cosmetic tattoo/permanent makeup or reconstructive tattoo procedure.

Touch up *

I understand that permanent makeup is a multi session procedure requiring more than one visit to perfect. All procedures take at least 30 days to completely heal. I understand that touch ups must be booked 30-60 days from date of the initial application.

Retin-A*

I understand that Retin-A or Renova must not be used around the treated area long term. I must stop use two weeks prior to my appointment.

Accutane*

I understand that I must be off Accutane 12 months prior to having any kind of permanent makeup procedure done

Tobacco Use*

If I am a tobacco user, I understand that the healing process may be negatively affected and I may have difficulty with color retention.

Fading/Fallout*

I understand that implanted pigment can change color or fade over time due to circumstances beyond the control of the performing technician. The original color may be altered by such things as sun exposure, tanning beds, skin care products, swimming pools, salinity levels of each person's eyes/skin, general health and other factors.

Permanence*

I accept the permanence of the procedure(s) as well as possible complications and consequences of said procedure(s).

Risks*

I have been fully informed of the inherent risks, associated with permanent makeup procedures. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. I fully understand that if I am unable to be still during my tattoo, it may result in blowout/fallout. Having been informed of the potential risks, I still wish to proceed with the tattoo application, and I freely accept and expressly assume any and all risks. I acknowledge and accept that the proposed procedure(s) all involve risks inherent in the procedure(s) and the possibility of complications exist both during and following the procedure(s). Infection misplaced pigment, migrating pigment, poor color retention, hyper pigmentation or fever blisters are a few of the possible complications.

Questions*

I certify that I have read and understand all of the above and have answered all questions truthfully and to my best ability. I have been given the opportunity to read and understand this document, that any and all of my questions have been answered, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the artist and the tattoo studio.

Photography*

I release all rights to any photography taken of me and the tattoo, I give consent in advance to their reproduction in print or electronic form.

Refunds/Touch Up*

I understand that there will be NO refunds after treatment of elective procedure(s). I understand my payment includes a total of 2 visits (consult, initial application, and touch up appointment). The touch up session must be scheduled for completion no later than 60 days from the date of the initial appointment. It is the responsibility of the client (you) to contact the technician within 30-45 days of initial application to schedule the touch up appointment.

Waive*

TO WAIVE AND RELEASE to the fullest extent permitted by the law each of the artist and the studio 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 result or arise from my tattoo, whether caused by the negligence or fault of either the artist or the studio, or otherwise.

Legan Action*

I agree to reimburse each of the artist and the tattoo studio for any attorney's fees and costs incurred in any legal action I bring against either the artist or the tattoo studio and in which either the artist or the tattoo studio is the prevailing party. I agree that the courts of (STATE) in (COUNTRY) shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

Influence

I am not under the influence of drugs or alcohol, and I am voluntarily submitting to be tattooed by the artist without duress or coercion.

PLEASE NOTE: Paperwork and ID is required for every visit with us. Please come prepared!

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Legal Name:*

Pronoun:

Chosen name:

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.