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Consent Form for Lip Blushing


I hereby authorize AZST to perform, upon myself, micro-pigmentation/permanent makeup. If any unforeseen condition arises in the course of the procedure(s) I further request and authorize my artist to use their best judgment to do whatever they deem advisable and necessary in the circumstances. 

I Agree

I understand that permanent makeup is an advanced form of tattooing.  

I Agree

I accept responsibility for determining the color, shape, and position of the enhancement as agreed during the course of my consultation. 

I Agree

I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware that allergic reactions are rare and accept all responsibility should an allergic reaction occur. 

I Agree

I am aware that a sensitive reaction to anesthetics can occur and accept all responsibility should any reaction occur. 

I Agree

I understand and accept that non-toxic pigments are used during the procedure and that the enhancement achieved will fade over the course of 1-3 years. Even though the color will fade, the pigment will remain in the skin indefinitely and may leave a residue of color. 

I Agree

I accept that the highest standards of hygiene are met and that sterile, disposable tools are used for each individual client, procedure, and appointment. 

I Agree

I understand and accept that new enhancements may require multiple procedures and applications of pigment to achieve the desired results and that 100% success cannot be guaranteed. I understand that this is why I will need to return for a follow-up appointment. I understand and agree that if I do not return for a follow-up appointment, I accept total responsibility for the final healed results. 

I Agree

I understand that the follow-up appointment must take place 1-3 months after the first appointment and any appointments that take place after this 3 month period will be chargeable at an additional fee. I understand that a 4-week period must pass to allow the procedure site to fully heal. 

I Agree

I understand that pigment may migrate under the skin, however, this is a rare occurrence. 

I Agree

I understand that micropigmentation (permanent makeup) is an invasive procedure and the process can be uncomfortable. 

I Agree

I am aware that the result of this procedure is determined by the following: 

  • Medication
  • Skin characteristics
  • Skin undertones
  • Alcohol and tobacco intake
  • Stress
  • Immune system health
  • Diet
  • Post-procedure care

I Agree

I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which usually subsides in 1-4 days dependent on the individual. In some cases, bruising may occur. I have been advised that I can resume normal activities immediately after the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration, and exposure to the sun should be limited for up to two weeks following the procedure. 

I Agree

I understand that, immediately after the procedure, the enhancement can be 30 to 70% darker than the desired result and can take between 4 -14 days to lighten. I understand that the true color will be visible 4 weeks after each application and that the color may vary according to skin tones, skin type, age, and skin conditions. I appreciate that some skins accept color more readily than others and no guarantee of an exact or color can be given. 

I Agree

I am aware that if I have had a previous outbreak of cold sores/herpes and receive a lip enhancement I may have an outbreak again following the procedure. I have been made aware that anti-herpes medication is available over the counter or on prescription and has been shown to prevent or minimize such outbreaks. 

I Agree

I understand that I may experience dry lips for up to 2 weeks following micro-pigmentation lip enhancement. 

I Agree

I understand that there are few effective methods for pigment removal. Laser and chemical removal have proven successful, however are a process. 

I Agree

I agree to inform any medical professional of my micro-pigmentation enhancement if I require an MRI scan. 

I Agree

I agree to make any technician who is conducting laser or IPL treatments close to my enhancement, aware that I have micro-pigmentation so that he/she can adapt his/her treatment plan accordingly. 

I Agree

I understand that a week before my menstrual cycle (if applicable) my body will be at its most sensitive. 

I Agree

I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. I understand that infection and possible scarring can occur if I do not adhere to the said instructions. 

I Agree

To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol. 

I Agree

For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s) 

I Agree

I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE MICRO-PIGMENTATION OF MY OWN FREE WILL. 

I Agree

I have read and understood the above information. 

I Agree

Pre-Procedure Design Template & Images

Subject to the agreed ‘Pre Treatment Design’ template being shown to me, as well as digital photographs being taken of the design template, I the client sign to say this is a true picture of the design requested.

I also agree to have digital photos taken immediately after my treatment so that there is a true comparison between what was requested for your file.

June 27, 2022


First Client Name

First Name*

Middle Name

Last Name*
First Client Date of Birth*
I certify that I am 18 years of age or older
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Additional Information

Artist Name
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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