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CONSENT FORM <br /> PERMANENT MAKE-UP PROCEDURE <br /> NAME: DOB: DATE: <br /> ADDRESS: CITY: <br /> STATE: ZIP: PHONE (Day) (Night) <br /> PROCEDURES DESIRED: Please Circle <br /> Eyebrows Lips Eyeliner <br /> I, am over the age of 18, am not under the influence of drugs or <br /> alcohol and desire to receive the indicated permanent cosmetic procedure. The general nature <br /> of cosmetic tattooing as well as the specific procedure to be performed has been explained to <br /> me. X <br /> I understand the permanent skin pigmentation procedure carries with it possible complications <br /> and consequences associated with this type of cosmetic procedure, including but not limited to; <br /> infection, scarring, inconsistent color, and fading of pigments. I understand the actual color of <br /> the pigment may be changed slightly due to the tone and color of my skin. I fully understand <br /> that inks are not FDA approved and health consequences are unknown. I request the <br /> permanent make-up procedure and accept the permanence of the procedure as well as the <br /> possible complications and consequences of the said procedure(s). X <br /> Following the procedure the client should expect redness, numb, and swollen around the area. I <br /> will strictly follow to all post procedure instructions. X <br /> I understand the taking of before and after photographs of said procedure is required. I certify I <br /> have read and initiated the above paragraphs and have had explained to my full understanding. <br /> CLIENT SIGNATURE: DATE: <br /> PRACTITIONER SIGNATURE: DATE: <br />