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Permanent Makeup – Eyeliner Consent Form

Procedure Description

Permanent eyeliner is a cosmetic tattoo procedure designed to enhance the lash line or eyelid by implanting pigment into the skin using a tattoo device. Styles may include lash enhancement, classic eyeliner, or winged eyeliner. Results are semi-permanent and vary by individual.

Risks & Acknowledgment

I understand that permanent eyeliner may involve swelling, redness, bruising, tenderness, light sensitivity, uneven pigment retention, infection if aftercare is not followed, allergic reactions, and rare scarring. I acknowledge that swelling around the eyes is common and temporary.

Color & Results Disclosure

I understand the eyeliner will appear darker and thicker immediately after the procedure and will soften as it heals. Final results may take up to 6–8 weeks. Multiple sessions may be required and results are not guaranteed.

Touch-Up Policy

I understand a touch-up appointment is typically recommended 6–10 weeks after the initial procedure and may be subject to additional fees if not included in my service package.

Aftercare Agreement

I confirm that I have received and understand the permanent eyeliner aftercare instructions and agree to follow them. Failure to follow aftercare may negatively impact healing and final results. 

Consent & Signature

I acknowledge that I have read and fully understand this consent form. I have had the opportunity to

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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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
Eye infection (current or recent)*
No
Yes
Dry eye syndrome*
No
Yes
Glaucoma*
No
Yes
Cataracts or eye surgery*
No
Yes
LASIK surgery (within last 6 months) *
No
Yes
Blepharitis*
No
Yes
Contact lens wearer*
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
Photography Consent*
I give permission for photographs/videos to be taken and used for portfolio, website, and social media
I do NOT give permission for photographs/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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