Consent Form for Semi Permanent Makeup
I hereby consent and authorise Madeline Becker to perform the following procedure:
Selected service(s) will appear here
Today’s date
Consent date
Client Details
Date of birth
Regular Doctor (optional)
Address (optional)
Emergency contact name
Emergency contact number
Emergency contact relationship
Please list any cosmetic procedures you would be interested in learning more about (optional)
Medical History
Current condition requiring treatment
Are you currently receiving any treatment from a doctor or specialist?
If yes, please give details (optional)
Are you currently suffering from any bacterial, viral or fungal infections?
Are you allergic to any medicines, antibiotics, foods or other substances?
If yes, please give details (optional)
Have you had any previous laser or skin peels?
If yes, please give details (optional)
Have you had any previous surgery or been admitted to hospital?
If yes, please give details (optional)
Please indicate if you have a history of the following conditions: (optional)
Please give details for anything ticked above, including dates, treatment, medication or anything Maddie should know before the appointment. (optional)
Are you currently pregnant or nursing?
Do you smoke/vape?
Do you drink alcohol?
If yes, how many units per week?
Do you take regular exercise?
If yes, what type of exercise do you do? (optional)
Do you suffer from any allergies?
If yes, please give details (optional)
Have you ever had an allergic reaction to any beauty treatment including injectables?
Do you suffer from Myasthenia Gravis or Eaton Lambert syndrome?
Have you had any form of cosmetic treatment, for example rhinoplasty, blepharoplasty, collagen injections, facelifts, aesthetic dental work or permanent hair removal?
If yes, please give details (optional)
Is there any other aspect of your health that you think we should know about? (optional)
Colours used (optional)
Semi Permanent Makeup Consent Statements
I confirm that I am above 18 years of age and affirm that I am not under the influence of drugs or alcohol. I further declare that I am not pregnant or nursing and express my desire to undergo the specified semi-permanent pigmentation procedure. I have received a comprehensive explanation regarding the general nature of cosmetic micro-pigmentation, as well as the specific procedure that will be carried out.
If any unforeseen condition arises during the procedure, I authorize my therapist to use their professional judgment to determine the necessary course of action under the circumstances. I take responsibility for selecting the color, shape, and placement of the Permanent Makeup procedure, as discussed during the consultation. I understand and acknowledge that non-toxic pigments are used during the procedure and that the achieved result may fade over a period of 1–3 years. Even as the color fades, the pigment itself may remain in the skin indefinitely.
I have been informed that strict hygiene standards are followed, including the use of sterile, disposable needles and pigment containers for each client, procedure, and visit.
I understand and accept that achieving the desired results is a process that may require multiple pigment applications, and that complete success cannot be guaranteed during the initial procedure. It may be necessary for me to return for additional procedures.
The outcome of the procedure can be influenced by various factors, including medication, skin characteristics including dryness, oiliness, sun damage, thickness or thinness, personal skin pH balance, alcohol consumption, smoking, and post-procedure aftercare.
After the procedure is completed, there may be temporary swelling and redness of the skin, which typically subsides within 1–4 days. Bruising may also occur in some cases. I can resume normal activities, but should limit the use of cosmetics, excessive sweating, and sun exposure until the skin has fully healed. Further instructions regarding aftercare will be provided. The results of the procedure should be acceptable for me to appear in public without additional makeup.
I have been informed that the true color of the procedure will be visible after 6 weeks, and the pigment may vary based on factors such as skin tone, skin type, age, and skin condition. It is understood that certain skin types may accept pigment more readily, and an exact color guarantee cannot be provided.
I agree to follow all pre-procedure and post-procedure instructions provided and explained to me by the technician. Failure to comply with these instructions may compromise the success of the procedure.
I acknowledge that I have received information regarding the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand that this cosmetic procedure is a form of tattooing, which is an art rather than an exact science. I am requesting this procedure with an understanding of its permanence and the possible complications and consequences associated with it.
I acknowledge that there is a possibility of having an allergic reaction to the numbing agent and/or pigments used during the procedure. While a patch test is offered, I understand that even if I undergo the test, it does not guarantee that I will not have an allergic reaction. If I choose to waive the patch test, I release the technician from any liability in the event that I develop an allergic reaction to the pigment.
I am aware that if I undergo any skin treatments, injectables, laser hair removal, plastic surgery, or other procedures that alter the skin, it may result in adverse changes to my permanent makeup procedure. I understand that some of these changes may not be correctable.
If you have a history of cold sores (Herpes Simplex Virus type 1), please inform your practitioner before your appointment. Certain treatments may trigger a flare-up. For clients with a known history of cold sores, we strongly recommend taking prescribed antiviral medication (such as Valacyclovir or Acyclovir) prior to treatment as directed by your healthcare provider. Medication is typically started 1–2 days before the appointment and continued afterward if advised.
I understand the importance of following the aftercare instructions provided to me by my artist. I acknowledge that failing to follow the correct aftercare may result in poor or undesired outcomes. I agree that my artist is not responsible for the results once I have left the treatment room, and I accept full responsibility for following the aftercare instructions as advised.
I have answered these questions to the best of my understanding.
