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e Informed Consent Form AESTHETICS Permanent Makeup Procedures Client Name: Date: I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure(s). The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me by my technician and/or by her or his associates including the usual risks inherent in the tattooing process, and the possibility of complications during or following its performance. I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor or temporary bleeding, bruising,redness,or other discoloration and swelling. Fever blisters may occur on the lips following lip procedures. Fading or loss of pigment may occur. Secondary infection in the area of the procedure my occur; however,if properly cared for,is rare. (Init) ® I understand a pigment(skin) test of the pigment to be used for my procedure is offered upon request and the test result is not assessed by a medical professional unless I make arrangements to have this done myself. A nonreactive skin test does not prevent an allergic reaction occurring at future point in time. I accept all associated risks of requesting or declining pigment (skin) test. I decline the skin test (Init) OR I request a skin test (Init) Please initial one of these options. Client Signature Date • I have informed my permanent cosmetic technician and/or her or his associates of any existing health problems. (Init) • 1 acknowledge that complications are always possible as a result of the permanent cosmetic procedure, particularly in the event my post-procedural instructions are not followed. (Init) • 1 acknowledge that hyperpigmentation (darkening of the skin) or hypopigmentation (the absence of color in the skin), or scarring is a possibility as a result of my body's reaction to the skin being broken during the procedure. I realize that my body is unique and that my permanent makeup technician and/or her associates cannot predict how my skin may react as a result of this procedure. (Init) • I acknowledge the receipt of written instructions advising me of the proper care of my procedure and I recognize the absolute necessity for following these instructions. (Init) ® 1 acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. (Init) • 1 understand that future laser treatments or other skin altering procedures,such as plastic surgery, implants, and injections may alter and degrade my permanent makeup. I further understand that such changes are not the responsibility of my permanent makeup technician. I further understand that such changes in my appearance may not be correctable through further permanent makeup procedures. (Init) • 1 am aware that cosmetic tattooing is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the procedure. (Init) • I authorize my permanent cosmetic technician and/or her or his associates to obtain pre-procedural and post-procedural photographs, and give her or him permission to use such photographs for publication and/or for teaching purposes, as she or he chooses. (Init)