Permanent Makeup Consent Form


Client Information:

  • Last Name:  
  • First Name:
  • Date of Birth:
  • Address:
  • City:
  • State:
  • Zip:
  • Phone:
  • Email: (Optional)

Procedure Selection: Please select the permanent makeup procedure(s) you wish to receive:

Health Information: Please answer the following health-related questions to safely perform your selected procedure(s):

  • Do you have or have had any of the conditions listed? Text
  • Are you taking any medication for blood thinning? Text
  • Do you have a problem with wounds healing? Text
  • Have you consumed drugs or alcohol within the last 24 hours? Text
  • Do you have any allergies?
  • Please list all medications you are currently taking:

Consent and Acknowledgements: By signing, you acknowledge and consent to the following:

  • Understanding of the cosmetic and elective nature of the procedure(s).
  • Being informed of possible effects, including infection, pigment fading, and allergic reactions.
  • Agreement to follow all provided pre- and post-procedure instructions.
  • Consent for photograph use by Katelyn McCloy for publication/teaching.
  • Acknowledgment that results vary and multiple sessions may be required, with no guarantees on the longevity or outcome.
  • Awareness and acceptance of specific risks related to the chosen procedure(s), including potential color and design changes during healing, risks of allergic reactions, and permanent changes to appearance.

Technician Information:

  • Full Name: Katelyn McCloy
  • Salon Addresses:
    • 810 CROGHAN STREET, FREMONT, OH 45069
    • 9059 CINCINNATI DAYTON RD, WEST CHESTER, OH 43420
  • Phone Number: (513)374-1587

Date:

Leave this empty:

Signature arrow sign here

Signed by Katelyn McCloy
Signed On: March 26, 2024


Signature Certificate
Document name: Permanent Makeup Consent Form
lock iconUnique Document ID: 481fef03b9e56d446294dc403a48e3206648f4c0
Timestamp Audit
February 27, 2024 11:44 pm ESTPermanent Makeup Consent Form Uploaded by - IP 99.17.220.229
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