Consent Form | E11EVEN BEAUTY

CONSENT TO PERMANENT MAKE-UP APPLICATION, RELEASE AND WAIVER OF ALL CLAIMS

I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent make-up from Kimberly Williams (hereafter called “Technician”) and that all of my questions have been answered to my full and total satisfaction.

First Name

Last Name

Date Of Birth

Month

Day

Year

Phone Number

E-mail

Street Address

City

State

Zip Code

Procedure to be performed:

Ombré Powder Brows

Ombré Powder Brows - Cover Up/Correction

Touch Up

I specifically acknowledge that I have been advised of the matters set forth below and agree (by checking each box) as follows:

I acknowledge that obtaining permanent make-up is my choice alone. I understand that the application of permanent make-up will result in a permanent change to my appearance, and that needles and inks will go into my skin.

No representations have been made to me as to the ability to later restore the skin involved in permanent make-up to the original condition, and it is very costly to remove.

I have truthfully represented to the Technician that I am 18 years of age or older.

I am not pregnant or nursing.

If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Technician and have been advised of any necessary steps to promote the satisfactory healing of my tattoo.

I acknowledge that I have no medical conditions that require doctor's clearance before receiving this service.

I do not have a recent history of medication use (blood thinners, accutane, botox/fillers, chemotherapy)

I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reaction to the permanent make-up process and further acknowledge that such reaction is possible.

I have advised the Technician of any allergies to anesthetics, soaps, or medications.

Allergies?

Yes

No

I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have a tattoo at this time.

I acknowledge and give consent to this permanent make-up studio to use images of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed, and/or television etc.

I understand that I will have permanent make-up applied using appropriate instruments and sterilization techniques. I understand that the permanent make-up site usually takes 2 weeks or longer to heal.

I acknowledge that infection is always possible as a result of permanent make-up application, and I agree to follow all suggested instructions concerning the care of the permanent make-up site while it is healing.

I acknowledge that I have been provided with verbal and written aftercare instructions for the procedure I am about to receive.

I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors, and the management of the permanent make-up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure.

Signature

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