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CONSEV FORM - f A E PERMANENT T C®S CS I hereby request and consent to the application of permanent color and consent to have the following procedures performed by: Please circle any of the fbilo iincil thpt may pertain to you: Eyeliner Eyebrows - Lip liner Full lip color Sear camouflage Beauty mask Areola repigmentation Other Please react and IIYi_IIII_The foliowincl statements- - I understand that the process used to apply color is not a one-step process and requires subsequent visits to achieve desired results. I further understand the fee includes my first visit and ONE perfecting visit. Maintenance touch-ups are scheduled as needed and may vary from six months to three years. Fees for maintenance visits, pigment replacements, and scar camouflage are based on any hourly fee. I understand that with time, pigment can (and will) fade and change color according to metabolism, skin type, medications, age, smoking, alcohol, sun exposure, Retin-A, and Glycolic acids. I acknowledge that no guarantees have been made to me concerning the results ofthis procedure and that the professional recommendation is a NATURAL LOOK. I understand the nature of the procedure and possible complications or adverse effects that may occur as a result of applied pigments. I fully understand this is a tattooing pr ess; therefore it is NOT considered a science, but an art*. �Rw►�ne n1 �9_oC_q,S S I have received and acknowledged pre- and post- procedure instructions, and agree to strictly adhere to such instructions. I accept responsibility for determining the color, shape, andpo skin. sition of the pigments that will be applied. I understand the actual color of the pigment may be modified slightly due to the tone &color of my I understand that the taking of before anafte photographs of procedures are required. 2n,K,s qRe not FDA a MLov �eloM con sc-9uen C e/> U ll)Y4i o W rt . a he knov-sr. possible Complications from micropigmentatior, are: redness,swelling, bruising, dry patches, and tenderness. It is normal to lose approximately 1/13 of the color during the healing process. After most procedures, the color may appear to be a shade too dark; in o days, it may appear to be too light. After 10 days, the color will show more initially. It will appear softer when completely healed, as the color will come from the dermal layer of the skin to the epiderma; layer of the skin. In the event of a CAT scan or an MRI, please inform your physician of your Iron Oxide Permanent Cosmetics, as some pulling or burning sensation may occur during the procedure. Client's signature: Date Witness signature- Date Practitioner signature: Date Form. 2