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Consent Form
<br /> CONSENT TO PREMANENT MAKE-UP APPLICATION,RELEASE AND WAIVER OF ALL CLAIMS
<br /> NAME:
<br /> PHONE: AGE: DOB:
<br /> ADDRESS:
<br /> CITY:
<br /> STATE: ZIP:
<br /> (acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent
<br /> ake-up (hereafter called"Technician")and that all of my questions have been answered to my full
<br /> and total satisfaction
<br /> Procedure to be performed: No.of visits required: Cost of Procedure(s):
<br /> I specifically acknowledge that I have been advised of the matters set forth below and agree as follows:
<br /> Initials at each line:
<br /> I have truthfully represented to the Technician that I am 18years of age or older.I am not under the influence of any drugs or alcohol.To my knowledge,I
<br /> 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 a tattoo at this
<br /> time.
<br /> I acknowledge that obtaining permanent make-up is my choice alone.The application of permanent make-up will result in a permanent change to my
<br /> appearance,and that needles and inks will go into my skin.I understand that after the procedure the actual color of the pigment may be modified slightly,due to the
<br /> tone and color of my skin.No representations have been made to me as to the ability to later restore the skin involved in permanent make-up to the original condition,
<br /> and it is very costly to remove.
<br /> I have been informed of the nature,risks,and possible complications and consequences of permanent skin pigmentation.I understand the permanent skin
<br /> pigmentation procedure carries with it known and unknow complications and consequences associated with this type of cosmetic procedure,including but not limited
<br /> to:infection,allergic reaction,scarring,inconsistent color and spreading,fanning or fading of pigments.
<br /> I understand I will have permanent make-up applied using appropriate instruments and sterilization techniques.I understand that the permanent make-up
<br /> site usually takes 2 weeks or longer to heal.I understand this is a tattoo process and therefore not an exact science,but an art.I request the microblading procedure and
<br /> accept the permanence of the procedure as well as the possible complications and consequences of the said procedure.I understand that while this is sometimes referred
<br /> to as semi-permanent in nature,due to each individual's reaction to pigment,the length of time pigment is present cannot be guaranteed.In some cases,pigment will be
<br /> permanent.
<br /> I agree to release and forever discharge,and hold harmless,the Technician,all employees,contractors,and the management of the permanent make-up
<br /> studio from any and all claims of negligence,damages,or legal actions arising from or connected in any way with my tattoo,the procedure,and conduct used in my
<br /> tattoo and assume all responsibility for the decision(s)made consenting to this permanent procedure.
<br /> ___I am aware that permanent cosmetic inks,dyes,and pigments have not been approved by the federal Food and Drug Administration and that the health
<br /> consequences of using these products are unknown.
<br /> I acknowledge infection is always possible as a result of permanent make-up application.I have received pre-and post-procedure instructions and I
<br /> understand them and will strictly adhere to such instructions.I understand that my failure to do so mayjeopardize my chances for a successful procedure.I agree that it
<br /> is my responsibility to contact my Technician if there are any signs and symptoms of infection,including,but not limited to redness,swelling,tenderness of the
<br /> procedure site,red streaks going from the procedure site towards the heart,elevated body temperature,or purulent drainage from the procedure site.
<br /> —I understand that the taking of before and after photographs of the said procedure are a condition of such procedure.I release all rights to any photographs
<br /> taken of tire and the permanent makeup and give consent in advance to this permanent make-up studio to use images of my tattoo(s)for marketing and,or publishing
<br /> Purposes in various media such as the internet,magazine,printed,and or television etc.
<br /> _I understand that if I have any skin treatments,laser hair removal,plastic surgery or other skin altering procedures,it may result in adverse changes to my
<br /> permanent cosmetics.I acknowledge some of these potential adverse changes may not be correctable.
<br /> I am not pregnant or nursing.I do not have any history of herpes infection at the proposed procedure site.I do not have epilepsy,diabetes,allergic reaction
<br /> to latex or antibiotics,hemophilia or other bleeding disorder.I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my
<br /> blood.
<br /> If I suffer from hepatitis,or other risk factors for bloodborne pathogen exposure,or any other communicable disease,I have informed the Technician of the
<br /> fact and have been advised of any medications and procedure necessary to promote the satisfaction healing of my tattoo.
<br /> I do not suffer from any medical or skin condition(s)such as,but not limited to:keloid or hypertrophic scarring,psoriasis at the site of the permanent
<br /> make-up,or any open wounds or lesions at the site of the tattoo.
<br /> I do not have a history of medication use or currently using medication,including being prescribed antibiotics prior to dental or surgical procedures.If I am
<br /> on any medication for depression or any other mood-altering prescription,I will advise my Technician.
<br /> PLEASE COMPLETE BOTH THE FRONT AND BACK SIDE OF THIS CONSENT FORM.
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