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Permanent Makeup – Lip Blushing Consent Form


Procedure Description

Lip blushing is a cosmetic tattoo procedure designed to enhance natural lip color, improve symmetry, and define lip shape. Pigment is implanted into the lips using a tattoo device. Results vary per individual and are semi-permanent.

Cold Sore Disclosure

I understand lip blushing may trigger a cold sore outbreak if I have a history of HSV and I am responsible for obtaining antiviral medication if needed.

Risks & Acknowledgment

I understand potential risks include swelling, redness, bruising, uneven color retention, infection if aftercare is not followed, allergic reactions, and rare scarring.

Color & Results Disclosure

I understand lip color will appear darker initially and fade 30–50% during healing. Final results may take 6–8 weeks and are not guaranteed.

Aftercare Agreement

I confirm I have received and understand aftercare instructions and agree to follow them.

Consent & Signature

I acknowledge I have read and understand this consent form and voluntarily consent to the procedure.

Date: February 21, 2026

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Appointment Date:

Medical History

Pregnant or nursing *
No
Yes
History of cold sores / herpes simplex*
No
Yes
Taking Accutane (within last 12 months) *
No
Yes
Blood thinning medications*
No
Yes
Autoimmune disorder*
No
Yes
Diabetes*
No
Yes
Keloid scarring *
No
Yes
Allergies to pigments, metals, latex, or anesthetics*
No
Yes
Immune disorders or healing issues*
No
Yes
Recent lip filler (within 4 weeks)*
No
Yes
Photography Consent*
I give permission for photos/videos to be used for marketing purposes
I do NOT give permission for photos/videos to be used
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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