Permanent makeup consent forms

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Email *

Full name *

Address *

Phone# *

Date of Birth

YYYY

What services are you getting done today?

Brows tattoo: shading or microblading

Eyeliner tattoos

Lip tattoo/ lip blush

Skin camouflage

Scalp micropigmantation

Nipple areola

Saline Tattoo Lightening/Removal

Other:

Do you have ANY allergies to lidocaine (numbing agent)?

yes

Are you have any allergies? if yes, please provide a short answer

Have you ever had any permanent makeup procedures before? Yes/ No

Yes

Clear selection

Are you taking any medications, including immunosuppressants, anti-inflammatories, or steroids? Yes/ No

Yes

Clear selection

Are you using any active products such as retinoids, hydroxyl acids, or other exfoliants? Yes /No

Are you taking Vitamin E or Aspirin regularly? Yes, your blood may get thin and it might push out the ink for micro blade brows

I’m 18 years or older *

Yes

Are you pregnant

Yes

Clear selection

Prior to the procedure, I will give Vallyn Nguyen my approval and will accept responsibility for pigment color and position of all permanent make-up on my eyebrows, eyeliner, lips and other areas… *

yes

I understand the nature, risk, and possible complications of permanent skin pigmentation. The risk of unwanted color and/or might needed multiple services necessarily for corrections. *

yes

I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to infection, allergic reaction, scarring, inconsistent color, and spreading, fanning, or fading pigments. *

yes

I understand that the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I understand that I might need multiple services to achieve the desired look. I understand that this procedure is an art, not an exact science. *

yes

I understand that tattooing is considered permanent; however, it may fade in time. That tattoo can only remove with a surgical procedure, and that any effective removal may leave permanent scarring or disfigurement. *

yes

Required

I understand that many factors can affect the outcome of these beauty services. Which includes, but are not limited to, issues such as stress, hormonal changes and certain medications. *

yes

I realize that there is a potential discomfort and pain during and healing process

yes

Clear selection

Exact colour cannot be determined and may need to be adjusted. All skin is different and more touch-ups may be needed. Colour needs to be checked every year. No refunds on permanent makeup. Please do not get this done if you are not able to get required touchups *

yes, I understand

I consent to the use of my photographs for advertising, records, and education purposes.

Yes

Clear selection

STATEMENT OF ACKNOWLEDGEMENT By signing below, I agree that I have read and fully understand the questions, terms, and disclosure conditions of this CLIENT release agreement for permanent makeup procedures, was completed by me and that all entries information in it, are true and complete to the best of my knowledge. *

I agree to consent Vallyn to work on my brows

Submit

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