Permanent Make-up Consent Form

    Permanent makeup Service Request:


    Medical History:


    Do you take daily medications? List Meds

    Do you have other health problems or medical conditions? List

    Do you take antibiotics prior to dental procedures? List

    Do you have previous Permanent Makeup? List

    Consent & Release Form Permanent Makeup

    The following information will help you to make an informed decision about whether to proceed with permanent cosmetic procedures. Please read and complete each section of this consent form.

    Permanent Makeup Pre-care, Aftercare, & Possible Risks
    • No waxing eyebrows or lip line 1 week prior to permanent makeup appointment.
    • We recommend no Vitamin E, fish oil, or turmeric vitamins 48 hours prior to your permanent makeup appointment.
    • Everyone heals differently and outcomes vary depending on skin type, lifestyle, and after care maintenance. The pigment can appear 30 to 50% darker immediately after and 24hour after the cosmetic tattoo procedure.
    • Keep the treatment area clean by washing with clean hands and a mild soap two times a day.
    • Apply a thin layer of A&D ointment with a Q-tip 3 times a day. Use the ointment very sparingly. Never touch the procedure area without washing your hands.
    • Eyebrows and lips begin to peel 3 to 7 days after the procedure. Rubbing, picking, or peeling the treatment area will result in scarring or scabbing and unfavorable results.
    • Not following the aftercare instructions correctly may result in an infection.
    • A touch-up appointment is necessary 5 to 8 weeks after the initial cosmetic tattoo procedure.
    • No makeup to the procedure areas for 2 to 3 weeks after your appointment.
    • The pigment will fade over time depending on skin type and lifestyle factors.
    • On rare occasion pigment migration under the skin may occur.
    • Although extremely rare, there may be an immediate or delayed reaction to pigments. Allergic reactions to anesthetic can occur.
    • There may be minor swelling or redness around the procedure area for 24 hours after your appointment. You may experience minor bleeding or minor discomfort during the procedure.
    • Signs and symptoms of infection include but are not limited to: red streaks or sever redness, elevated body temperature, or purulent drainage from the procedure site. We advise you to seek medical care if you have any signs or symptoms of infection.
    • Permanent makeup is contraindicated for anyone under the age of 18 years, taking blood thinners, pregnant, or breastfeeding.
    Permanent makeup is a cosmetic tattoo procedure that deposits pigments between the epidermis and dermis layers of the skin.

    Modern Beauty Glam uses sterile single use disposable needles and disposable pigment containers. Cross contamination and bloodborne pathogen guidelines are strictly adhered to.

    A touch-up appointment is necessary 5 to 8 weeks after the initial cosmetic tattoo procedure to achieve optimal results. A perfect result is not a realistic expectation after an initial application. In certain cases, a third procedure may be needed.

    The pigment can appear 30 to 50% darker immediately after and 24hour after the cosmetic tattoo procedure. The treatment area should begin to peel 3-7 days after the procedure. You should see less swelling, and the color should soften 30%. The pigment will fade naturally over time and will likely need a touch-up through the years.

    Prior permanent makeup work done by a different artist could interfere with the desired results. A telephone consultation for permanent makeup color correction is necessary before booking an appointment.

    It is the client’s responsibility to explain to the artist the desire for specific colors, shape, and position for any procedure.

    I agree and consent to receiving this permanent makeup procedure.

    I understand that the procedure I chose is for cosmetic purposes only and NO Guarantees have been made regarding the results of the procedure.

    I understand that color saturation cannot be guaranteed. I understand that a touchup appointment 5 to 8 weeks after the initial procedure is necessary. I agree that any touch up work needed will be done at my own expense.

    I understand that any skin treatments such as but not limited to  Retin A, Renova, Alpha Hydroxy and Glycolic Acids, laser hair removal, plastic surgery, or other skin altering procedures may result in adverse changes to my permanent makeup. I understand that sun, tanning beds, pools, some skin care products, and medications can affect my permanent makeup.

    I acknowledge that the proposed procedures involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, poor color retention, and hyper-pigmentation.

    I acknowledge that although extremely rare, there may be an immediate or delayed reaction to pigments. A negative patch test result does not guarantee you will not develop an allergic reaction after the full procedure. I release Modern Beauty Glam from liability should I develop an allergic reaction to the pigment.

    I have read all the Pre-care/Aftercare guidelines and acknowledge that Aftercare instructions are available on www.modernbeautyglam.com. I agree to follow them to the best of my ability.

    I grant permission to Modern Beauty Glam, to take and use photographs and/or digital images of me for documentation purposes, use in educational materials and/or social media platforms.

    Deposit Policy:
    Permanent Makeup appointments require a $150 deposit. This is a non-refundable deposit that will be applied towards the remaining balance of your treatment at check-out.

    Cancellation policy: We require 48-hour notice for a no fee cancellation. Cancellations less than 48 hours from the appointment time will forfeit the non-refundable deposit and will not be able to transfer the deposit to a later date. Touch-up cancellations less than 48 hours from the appointment time will incur a non-refundable cancellation fee of 50% of the service procedure and will be charged to the card on file or added to the next service appointment. Same day cancellation will be charged 50% of the service procedure and forfeit the non-refundable deposit. No call no show will be charged 100% of the service procedure and forfeit the non-refundable deposit.

    Late Policy
    Please note that we have a 15-minute late policy. Arriving 15 minutes late for your appointment will be considered a no show. We reserve the right to CANCEL and give no refunds if the client is more than 15 minutes late to their appointment. If you are late, you may schedule a new appointment but will need to make a new deposit.

    No Refunds
    Modern Beauty Glam does not offer refunds, no exceptions.

    Anti-Fraud Policies
    By signing below, you acknowledge that the credit card or debit card used to book was your card and you are not paying for the service in a fraudulent manner.
    If the card being used is NOT yours, you acknowledge that the person paying for you is someone you personally know and has already completed and signed our Credit Card Authorization Form prior to you booking your appointment. If at any time the person paying for this service issues a chargeback, you will be personally liable for the full amount of the chargeback. If there are any unresolved chargebacks, your file will be submitted to Small Claims Court of Broward County.

    I certify that I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all my questions have been answered. I acknowledge that I have reviewed and approved the material given to me.

    By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement.

    Sign below