Permanent Makeup Consent Form


Client Information:

  •  

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
  • 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:

Leave this empty:

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Signature Certificate
Document name: Permanent Makeup Consent Form
lock iconUnique Document ID: 9feb8acb83f46833e2daae26e56373a7303d7bce
Timestamp Audit
May 9, 2025 7:08 pm EDTPermanent Makeup Consent Form Uploaded by - IP 103.255.67.144
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