Permanent Makeup Release Permanent Makeup Release Name First Last Date of Birth* MM DD YYYY PhoneEmail Procedures Select all that apply: Microblading Powder Brows Eyeliner (Upper) Eyeliner (Lower) Eyeliner (Upper and Lower) Lip Liner Full Lip Color Consent select each statement after reading: I am over the age of 18 I am not under the influence of drugs or alcohol and desire to receive the indicated permanent cosmetic procedure(s). I understand that permanent skin pigmentation procedure carries with it possible complications. Including but limited to: scarring, inconsistent color, migration or fading of pigments. I understand this is a tattoo process and therefore not a science but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s). I understand there may be a certain amount of pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration, and swelling 12+ hours post procedure. This is normal, you may apply ice for no more then 15 minutes at a time. I understand and accept that such procedure is a process, often requiring more than one application of color and that 100% success cannot be guaranteed. It is understood that I have the option to receive a patch test at least 24 hours prior to the procedure, that if I waive such a test, I will be full responsible on any form of allergy that may occur associated with the said procedure. Depending on the procedures which I select, I accept responsibility for determining the color, shape, and position of eyebrows, eyeliners, lip liner and/or full lip color. I will follow all after-care instructions that my technician gives me. I will not use products that are not directly given to me by my technician. I accept all responsibility for my procedures. If I move during the procedure, I am responsible for all mistakes, not the technician. Using AHA or any skin lightening or exfoliating product on or around my procedure, area will compromise the procedure and I accept responsibility for fading and future color refreshers. Eyebrows are "Sisters" not "Twins" they will never be perfect because of muscle, tissue and bone formation of the forehead. We will make them as symmetrical as possible. We generally do not go outside of the lip line with colour. All applications are to make you look like you have natural beautiful lips and not like you are wearing heavy makeup. If there is any uneven pigmentation in my lips (blue, brown or darker spots), these darker areas will pull darker colour and my lip colour will look uneven. When you are warm your lips will appear pinker and when you are cold your lips will appear bluer. If you can not tolerate the procedure and the technician can not finish the procedure I will be charged a set-up fee for $75. We will not perform any procedure that we are not in full agreement with: Shape of brows, eyeliner or lips. Plumberry Skin Care has a "No Refund Policy" and I am aware of this. If you pick at the crusting you will lose your pigment in that area making your procedure uneven. Prior permanent makeup: If I have had permanent makeup applied previously, the technician will not be held responsible for colour inconstancy, fading, or any other problem relating to the new procedure. Prior Permanent Makeup: Your procedure is not considered a "Touch Up" for the new technician. We do not know what pigments were used, if your needle was disposed of properly, if cross contamination occurred, or any other hazardous behavior was displayed. Full price fees will be charged for each procedure. I am honest with all of my answers on my medical history form and all of my consent and procedure forms. Noncompliance with these questions will compromise my results. I have read and consent to have the treatment site(s) photographed before, during and after treatment and that these photographs are the property of PlumBerry Skin Care and may be published on our website or displayed in print or electronic media. Identifying information will not be disclosed. Cancellations Policy: We require 24 hours for any cancellation otherwise my credit card will be charged for half of the quoted, original procedure amount. Deposit: A $75 non-refundable deposit is required at the time appointment is made. Date SignatureCommentsThis field is for validation purposes and should be left unchanged.