Client Intake & Consent | Shana Style

Section 1 of 6

General Information

First Name *

Last Name *

Date of Birth *

Email *

Cell Phone *

Home Phone

Ethnic Background (include all nationalities)

Street Address

Apt. #

City

State

Zip

Occupation

Confidentiality if we call at home

OK to call at work

Emergency Contact

Relationship

Emergency Phone

Who may we thank for referring you?

Procedure(s) Desired *

Section 2 of 6

Medical History

Current Medications (name, dose, why prescribed)

Medications in last 6 months (no longer taking)

Do you have?

Notes (specify dermatological disorder, allergies, etc.)

Do you use?

Notes (when for Botox / chemical peels, etc.)

Have you had?

Notes (when, where, type)

Are you?

PregnantPlanning cosmetic surgeryCurrently under care of a physician

Notes

Outdoor activities

Other outdoor activity

Physician Name

Physician Specialty

Physician Phone

Physician Address

Section 3 of 6

Informed Consent

Please read each statement carefully and enter your initials to confirm.

1. Are you currently pregnant or nursing? *

No Yes

2. I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results, and that 100% success cannot be guaranteed.

Initials *

3. I have received, reviewed, and understand the pre-procedural instructions as given to me and agree to follow them.

Initials *

4. Depending on the procedure(s) I select, I accept responsibility for determining the shape and position of eyebrows, eyeliner, lip liner, and/or full lip color.

Initials *

5. I understand that color selection and color results in all procedures are not an exact science.

Initials *

6. I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox, or Restylane, and I assume this responsibility.

Initials *

7. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics.

Initials *

8. If I am a contact lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.

Initials *

9. I understand that this procedure will fade and this fading can alter the original pigment color, and that this determines when it is time for a touch-up visit.

Initials *

10. I realize this is an elective cosmetic procedure and is not medically necessary.

Initials *

11. It has been explained to me that the following possibilities may occur: minor and temporary bleeding, bruising, redness, or other discoloration; swelling; fever blisters on the lip area following lip procedures; and/or fading or loss of pigment.

Initials *

12. I understand that many lasers & IPLs may turn permanent makeup dark or even black. I agree to inform my esthetician of my permanent makeup.

Initials *

13. I give my consent to Shana Style Blushing to confer with my physicians for medical information required for the safety of my procedures.

Initials *

14. I agree to accompany my practitioner to the emergency room if they are accidentally stuck with my needle, and to take a blood test for their safety.

Initials *

15. I am aware that if an infection occurs after I have received Permanent Cosmetics, I will see my primary physician or go to an emergency room immediately.

Initials *

Section 4 of 6

Photography & Media Release

Check each use you authorize. Your name and personal contact details will not be disclosed with images without additional written consent.

Educational purposes and client consultationsSocial media platforms (Instagram, Facebook, TikTok, etc.)Website portfolio and marketing materialsBefore-and-after showcase / client testimonialsPrint materials (brochures, flyers, advertisements)I do NOT consent to the use of my photographs for any of the purposes above.

Printed Name *

Section 5 of 6

Minor Consent

The client receiving this procedure is a minor (under 18). I am the legal guardian and consent on their behalf.

Section 6 of 6

Aftercare Acknowledgement & Signature

I acknowledge that I have received and understand the post-procedure aftercare instructions for my procedure(s), including pre-care, day-of, and the multi-week healing process. I understand a 6–12 week touch-up is required to consider any PMU procedure complete. I will avoid sun, swimming, saunas, makeup on the area, and picking at the pigment as instructed. I agree to call 601-410-1831 with any questions or concerns and to seek medical attention at the first sign of infection.

Your Initials *

Client Signature (applies to entire packet) *

Sign here with your mouse or finger

Date