Permanent Makeup Client In-Take Form

I certify that I am a competent adult of at least 18 years of age

I certify that I am a minor under the age of 18 and understand that the consent of my parent/legal guardian will also be required before treatment.

I understand that an allergy test does not guarantee that I will not develop an allergic reaction to the pigment

I understand that I am offered and can voluntarily have a patch test to determine if I am allergic to the pigment. Once the test is performed client must wait a period of 5 days before any procedure to determine if client is allergic. 

I understand that the color intensity with be significantly darker and sharper immediately after procedure and will reduce by 10-15%.

I acknowledge that Permanent Makeup may involve risks or complications during or following the procedure such as, but not limited to, infection, misplaced pigment, poor color retention or hyperpigmentation.

I understand that implanted pigment color can change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touchup session within 4-6 weeks. 

I understand that sun, tanning beds, pools, skin treatments, laser hair removals, skin care products, medications, or other skin altering procedures can affect my Permanent Makeup.

I understand I must wait at least one month following my Permanent Makeup procedure before donating blood. 

I have received pre- and 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.

I have been quoted the cost of today’s appointment, and the cost of the touchup. Touchups must be completed within 4-6 weeks of initial procedure to be considered at the first free touchup price.

I understand that there will be no refunds upon treatment for this elective procedure. 

If an unforeseen condition arises during the Permanent Makeup, I authorize my therapist to use their professional judgment to decide on what he/she feels necessary in the given circumstances. 

I understand that a certain amount of discomfort is associated with this procedure and that minor or temporary swelling, or redness may occur following permanent makeup procedure. Fading or loss of pigment can occur. I am getting this procedure done at my own risk and cannot hold Mirage MedSpa or Mirage MedSpa’s employees liable for any problems, infection, risk, damage, scarring, dissatisfaction, or other problems that may occur.

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to a Permanent Makeup procedure by Mirage MedSpa’s Permanent Makeup Technician without duress or coercion.

I hereby consent to having Permanent Makeup applied by Mirage MedSpa’s Certified Technician.

I have answered all questions truthfully and to the best of my knowledge.

I certify that I have read and understood all the above.

I consent to allowing Mirage Salon & MedSpa permission to use the photographs on their social media for promotional purposes.