Permanent Makeup Consent | Contoursbeautyink

CONTOURS BEAUTY INK

6109 Camino Real

Jurupa Valley CA 92509

Permanent Makeup Client Information

Complete this packet before treatment. Read the procedure information, answer every medical question, and sign the required consent sections. Ask your practitioner to explain anything you do not understand. You may decline the procedure or ask to stop at any time.

Practitioner name

Practitioner registration number

Full legal name

Date of birth

Age

Appointment date

Telephone

Address

Client Photo Identification

Place or attach photocopy of client photo ID to the confidential client record.

Original government-issued photo ID reviewed.

Client identity and age 18 or older verified.

Verified by (staff) and verification date are recorded below.

Verified by (staff)

Verification date