COMPLIANCE INFO_CARRIE BLUBAUGH - Laserfiche WebLink

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0 0 • I am aware that the herpes simplex virus type 1 (HSV-1) (fever blisters or cold sores) may occur as a result of a lip procedure due to trauma to the lip tissue. The anticipation of an outbreak may be pretreated with antiviral medication, available by prescription from your physician. (Init) ® I understand that tattoos may cause MRI (Magnetic Resonance Imaging) artifacts and that there may be a warning and/or tingling sensation in the permanent cosmetic procedural area during the MRI due to the iron oxide (metallic salts) properties of some pigments. It is understood that I should advise my physician that I do have permanent cosmetics (a tattoo) in the event an MRI procedure is prescribed. (Init) • The fee for permanent makeup services has been explained to me and has been agreed upon. I understand the total fee for services rendered is due upon completion of the initial procedures and that there will be separate fees for any future modification of the design or major color change. (Init) • Due to the fact that my approval is obtained prior to final selection of color to be implanted and design applications to be applied, my technician employs a no refund policy. (Init) • For some skin types and procedures,permanent cosmetics may be a multisession process. In addition to your initial application,you are entitled to a post-evaluation appointment. At the post-evaluation appointment, it will be determined if a touch-up to the initial application is required. You must schedule your post-evaluation appointment before leaving your initial procedure. (Init) • It has been explained to me that immediately after the procedure is completed,the color will appear darker than when the procedure heals. It has also been explained that within a short period of time, during the healing process,the color will soften. (Init) ® All color fades-this is a fact that also applies to pigments (also called colors,colorants, and formulations) used for cosmetic tattooing. After your procedure has been performed and any subsequent work performed at the post-procedure appointment, the pristine appearance of your permanent cosmetics is very dependent on daily maintenance of avoiding direct sunlight (intentional tanning), avoiding strong chemicals applied to the procedural area,and applying a sun block product daily (frequently if in a situation where activities take you in the sun). Color refreshers will be needed at some point in the future. The time frame for that need cannot be predicted, as this aspect of permanent cosmetics is very client specific. If the procedural area is dense enough (can be easily seen) that one application of pigment will bring the color back to it's original appearance,a color refresher fee will be charged that represents a lower charge than the fee charged for new work. If the procedural area is extremely light and only represents a weak version of the original procedure, or if it is not visible, a procedure fee for new work will be charged. (Init) ® I understand that inks are not FDA approved and health consequences are unknown. (Init) • I have read and understand the contents of each paragraph above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from,or consequences of,the aforementioned procedure. (Init) • Your signature below represents consent for permanent cosmetic services and shall remain in effect during the entire period you remain a client of Aesthetics Lash Ink. (Init) I acknowledge by signing this consent form, I have been given full opportunity to ask any and all questions about permanent makeup procedures and processes from my permanent makeup technician and/or her associates. Client Date I personally reviewed the above information with my client, or the client's representative. Permanent Cosmetic Technician Date