Permanent Makeup Contract
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First Name
Last Name
Email
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Phone
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What services are you interested in?
Skin type
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Combo
Dry
Oily
Medical History
Check mark if you have or had any of the following conditions.
List any medications you are currently taking. Please include any antibiotics you have taken prior to detal or surgical procedures:
Medication History
Do you have any allergies to any medications, if so please list them.
Are you allergic to topical salves such as Bacitracin, lanolin, lidocaine, novocaine, metals, neosporine, rubber gloves, latex, epinephrine, tetracaine, benzocaine, if so please list what you are allergic to.
Are you using any eye drops or ocular medications?
Person to contact in the case of an emergency
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First Name
Last Name
Phone number of emergency contact person.
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DISCLOSURE AND CONSNET FOR PERMANENT MAKEUP
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I, the client, have requested that you describe the procedure to be utilized so that I may make an informed decision wither or not to undergo the procedure. DESCRIPTION OF THE PROCEDURE: This procedure is to be used as Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin. Micro pigment implantation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage. I, the client, voluntarily request as my intradermal cosmetic technician, Christal Caladiao, as she deems necessary to perform on my body, the micro blading or nano machine procedure.
Drivers License number:
Your age:
Birth Date
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MM
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Additional notes on history such as keloids, cold sores or medications that will effect services:
By checking this, I the client, understand this is a binding contract.
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Signature. By Typing my name, I agree to secure this contract for PMU Services
Contract Date
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