PMU Release

Permanent Makeup Consent Release Form

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Name *

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I acknowledge by signing this form that I have been given the full opportunity to ask any and all questions I might have about obtaining a permanent makeup/tattoo from Gigi Strength at The Gi Spot Beauty Salon. I acknowledge that all my questions have been answered to my full and total satisfaction. I am aware that this record will remain on the premise for a minimum of three (3) years and will be available for review by the Fremont County Health Department and other state regulatory agencies. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows:

I understand The following information shall be documented and used by the body artist to determine the client’s suitability for receiving a body art procedure. In order to assure insofar as possible the proper healing of a client following a body art procedure, the client shall be asked to disclose if he/she has any of the following: *

I acknowledge that Permanent Makeup services and body art is considered a permanent alteration to my appearance. *

Please checkmark any box to disclose if you have any of the following conditions: *

Diabetes Hemophilia Skin diseases or skin lesions Allergies or adverse reactions to latex, pigments, dyes, disinfectants, soaps or metals Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting

I am NOT under the influence of alcohol or drugs. *

I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing excluded) *

I acknowledge that I am free of communicable disease. *

I acknowledge that it is not reasonably possible for the associates, agents and representatives The Gi Spot Beauty Salon to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my permanent makeup session and I agree to accept that such risks are possible. *

Please disclose any other information that would aid the body artist in your body art healing process. *

I have looked over my design and give my full consent to the application of my permanent makeup. *

I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about permanent makeup procedure have been answered to my satisfaction. *

I acknowledge that applying permanent makeup is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove the permanent makeup. *

I agree to release and forever discharge and forever hold harmless The Gi Spot Beauty Salon and its associates, agents, officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my permanent makeup or the proceedures and conduct used to apply my permanent makeup and any and all permanent applied by The Gi Spot Beauty Salon and its associates, agents and representatives in the future. *

I agree to follow all instructions concerning the care of my permanent makeup, and that any touch-ups needed because of my own negligence will be done at my own expense. *

I acknowledge that the obtaining of my permanent makeup is my choice alone and I consent to the application of the permanent makeup and to any actions or conduct of the associates, agents or representatives of The Gi Spot Beauty Salon that are reasonable necessary to perform the permanent makeup procedure. *

I acknowledge that I am NOT Pregnant. *

I acknowledge that I have truthfully represented to the associates, agents and representative of the Gi Spot Beauty Salon that I am over the age of eighteen (18) years of age. *

I acknowledge that infection is always possible as a result of obtaining a permanent makeup application, particularly in the event that I do not take proper care of my permanent makeup, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. *

I acknowledge that variations in color and design may exist between any permanent makeup as selected by me and as ultimately applied to my body. *

I acknowledge that permanent makeup inks, dyes and pigments have not been approved by the Federal Food & Drug Administration and the health consequences of using these products are unknown, *

I acknowledge that there is a chance I might feel lightheaded, dizzy during or after having a permanent makeup procedure. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. *

I have been fully informed of the risks of permanent makeup including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to permanent makeup pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with getting a permanent makeup service, I still wish to proceed with permanent makeup application and I assume any and all risks that may arise from receiving a permanent makeup procedure.

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