Permanent Makeup Consent Form Template – US

Consent for Semi-Permanent Cosmetic Procedure

The information provided here serves as a general guideline for individuals considering a semi-permanent cosmetic enhancement procedure. It is not intended as legal or medical advice. Users should consult licensed professionals to understand the risks, benefits, and requirements pertinent to their specific circumstances. Regulations and standards may vary by location, and it is advised to ensure all protocols are followed accordingly. Use of this template is at the user’s own risk; we do not accept liability for any inaccuracies or outcomes resulting from its application without professional oversight.

Please note: This document serves as a sample Permanent Makeup Consent Form for informational purposes only. Actual consent forms may vary based on clinic policies and applicable regulations.

Permanent Makeup Consent Form Sample

Client Information:

Name: ________________________________
Date of Birth: ________________________________
Contact Number: ________________________________
Email: ________________________________

Procedure Details:

Procedure: / Permanent Eyebrows / Eyeliner / Lip Blush / Other: ________________________________
Description: The client has been informed about the permanent makeup procedure, including expected outcomes, possible risks, and aftercare instructions.

Acknowledgment and Consent:

I hereby confirm that I have been fully informed about the nature of the permanent makeup procedure, including the risks, benefits, and potential complications. I understand that results may vary and that touch-up procedures might be necessary. I consent to the procedure and agree to follow all pre- and post-treatment instructions provided by the practitioner.

Practitioner:

Name: ________________________________
License Number: ________________________________
Contact: ________________________________

Signature of Client: ________________________________
Date: ________________________________

Additional Terms:

• The client agrees to disclose any allergies, skin conditions, or medications that may affect the procedure.
• The client understands that individual results vary and that certain factors may influence healing and pigmentation retention.
• This consent is valid for one procedure session unless otherwise specified.

Location: ________________________________
Date: ________________________________