Permanent Makeup Procedure Consent Form

Name:__________________________________________________ DOB:_________________


City:_______________________________________ State:_________________ Zip:________________

Phone:_________________________ Emergency Contact Phone:__________________________

E-mail:___________________________________________ Referred By:_________________________

Micropigmentation is the process of placing pigment into the dermis. This process is considered a tattoo. These pigments can last from one to a few years, depending on skin tone and the intensity of the color that is used. Lighter skin tones will not hold the color as long as darker skin tones and may require an occasional touch-up to prolong the results of the procedure.

Current prices for permanent make-up are as follows, retouch for all services are $150:

Upper/Lower Eye Liner - $295

Upper Eye Liner Only - $210

Lower Liner only-$185

Powder Eyebrows /ombre/microblade) - $295

Ombre brows with microblade- $345

Micro Needling-$150

Lip Liner $180, full lip: 480,

Scar Camouflaging- $230/hr (flat rate base on size)

Tattoo Lightening/camouflage- 100/hr or flat rate available base on size

Nipple / Areola Repigmentation $500

Scalp Repigmentation (Hair Follicles Replication) 1000-2500 (complete job, includes touch-ups)

*Touch-ups: The need for a touch-up varies from person to person. Touch-ups cannot be scheduled any sooner than four weeks following the previous procedure. The skin needs at least four weeks to completely heal and may need longer with elderly patients, health problems and/or smokers. Not apply Scalp repigmentation and scar camouflaging.

Medical and Skin History

Are you pregnant/ nursing? Yes No

Do you smoke? Yes No

Do you wear contact lenses? Yes No (if yes, they must be removed for the eyeliner procedure)

Do you have ANY allergies? Yes No (if yes, please specify:__________________________________________________)

Do you have any tattoos? Yes No

Have you ever had any permanent makeup procedures before? Yes No

Are you taking any medications, including immunosuppressants, anti-inflammatories, or steroids? Yes No

Are you able to take over-the-counter antihistamines? Yes No

Are you allergic to any topical antibiotic preparations? Yes No

Have you EVER had a cold sore? Yes No

Are you using any active products such as retinoids, hydroxyl acids, or other exfoliants? Yes No

Are you taking Vitamin E or asprin regularly? Yes No

Do you have any medical issues? ___Yes ___No If yes, Please explain:________________________________________________________________________________________________


______I’m not pregnant and I consult with my doctor prior to my procedure.

______I’m 18 years or older.

_______Prior to the procedure, I will give Vallyn Nguyen my approval and will accept responsibility for pigment color and position of all permanent make-up on my eyebrows, eyeliner, lips and other areas…

_______I have read and understand the nature, risk, and possible complications of permanent skin pigmentation.

_______I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type if cosmetic procedure, including but not limited to infection, allergic reaction, scarring, inconsistent color, and spreading, fanning, or fading pigments.

________I understand that actual color of the pigment may be modified slightly, due to the tone and color of my skin. I understand that I might need multiple services to achieve the desire look. I understand that this procedure is an art, not an exact science.

_______ I understand that tattooing is considered permanent; however, it may fade in time. That tattoo can only remove with a surgical procedure, and that any effective removal may leave permanent scarring or disfigurement.

_______I understand that many factors can affect the outcome of these beauty services. Which includes, but are not limit to, issues such as stress, hormonal changes and certain medications.

________I have received post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure and may result in loss of pigment.

________I realize that there is a potential discomfort and pain during and healing healing process.

________Exact colour cannot be determined and may need to be adjusted. All skin is different and more touchups may be needed. Colour needs to be checked every year. No refunds on permanent makeup. Please do not get this done if you are not able to get required touchups.

_______I consent to having before and after photographs for the purposes of documentation.

_______I consent to the use of my photographs for advertising and patient education purposes.


By signing below, I agree that I have read and fully understand the questions, terms, and disclosure conditions of this CLIENT release agreement for permanent makeup procedures, was completed by me and that all entries information in it, are true and complete to the best of my knowledge.


Signature of the Client Date


Print name


Technician Signature Date