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t r <br /> Artist: Contact: <br /> I, , am 18 years of age or older and as a client have requested that <br /> you descr_be the procee-ure to be utilized so that I may make an informed decision whether or not to undergo <br /> the procedure. <br /> You have descr_bed the recommended procedure to be used as Permanent Makeup, the process of <br /> implantin, micro insertions of pigment into the dermal layer of skin Permanent Makeup is a form of <br /> tattooing and the markings are permanent. <br /> I understand that there are no tattoo or permanent makeup pigments that have been approved by the <br /> federal Food and Crug_administration The health consequences of using these products are unknown. <br /> I voluntarily request as my intradermal cosmetic technician, <br /> and such association and technical assistance as she may deem necessary to perform on my body the following <br /> proceduTE (circle one): <br /> UPPER FIELID LOWER EYELID LOWER MUCOSAL EYELID EYEBROW FULL LIP COLOR LIPL.INER AREOLAS <br /> SCARCAMOUFLAGE SFF_ETCH MARKS OTHER: <br /> Please Initial: <br /> I hereby authorize <br /> to take photograpls/video of the work performed both before and after treatment,and I further authorize the <br /> use of said photo&naph.- to be used for the purpose of advertising. <br /> I have inf-x-med that I am in good health and not under the care of any physician. <br /> �I am currently i:nder the care of a physician and I am being treated for the following condition(s): <br /> Physician's Name: Phone Number: <br /> Address: City/State: Zip: <br /> Please Initial: <br /> I have been given a copy of after care and acknowledge that failure to follow instructions may result in <br /> loss of color,discoloration,infection ect. <br /> =have been told that there may be known and unknown risks and hazards related to the performance <br /> of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to <br /> the results. <br /> acknowtedge the manufacturer of the pigment to be applied requires spot testing and specifically <br /> disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may <br /> identify individuals who develop an immediate allergic reaction to pigment, <br /> /Users/shawmfoVDes1do¢/2017 REVISED Consent Form(UPDATED)(2).doex Rev:12/5/2M6 Page 3 of 8 <br />