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:

• Select Your ServiceBrowsEyelinerLips

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

Date: