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Consent Dorm
<br />CONSENT TO PERNIAXENT MAKE-UP APPLICATION, RELEASE AND WAIVER OF ALL CLAIMS
<br />ADDR
<br />CITY:
<br />AGE: DOB:
<br />STATE: ZIP:
<br />I 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 />make-up from (hereafter called "Technician") and that all of my questions has been answered to mfull
<br />and total satisfaction. y
<br />Procedure to be performed:
<br />So. of visits required: Cast of Prosed ure(s):
<br />I specificalhacknwvledge that I have been adv iced of the matters set forth below and agree as follows:
<br />Initials at each line
<br />[ base tmthtidly represented w the Techninan that I am 18years oFase or older. I am no! under the in Fluence of an} dines or alcohol To my knowledge. 1
<br />da not base any phy stcah menial, or medical impairment or disabibry that might affect my well being as a direct or indirect ms:J; of my dcluion to bare a tattoo at this
<br />time
<br />I acknowledge that obtaining, permanent make map is my choice alone The application ofpermanent makeup mill result to a permanent change to my
<br />appearance,and that needles and inks w ill 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 rci) costly to remote
<br />I h;rve b- fe mizd of the namrc risks and pm. -h iplicatiuns and con, y f p rma nt ,Amp e C I u d tend th p m t spin
<br />topigmentationinfection,
<br />per is - - til t known J unknow con pl C d um,zquenez, 1 with tills type of xnetic procedure, including but not trotted
<br />try infect nn, allerg ,,tion, sc, ng, inconsistent color and .I ad t _. fanning o !odm_ of ingolents.
<br />I undcrs;anA I will have pmn:urunt make-up appli
<br />ed using appropriate instrument, and stznlizatian tachniyu y. I undzrr:md that the pztmanznt maks-up
<br />s'tz u r AeN2 w ec i or inigato heal I understand this i, a ontooloncess and therefore not an exact se ence hitan an I request die m t,roblad-ng, procedure and
<br />accept the permanence of the procedure a, well as the p "Ohlz complications and con;equcnces of the sad procedure I understand that wh le the is so naCtr e, retested
<br />to as Neon -prnmu:znt 1t wan re, due to each nodi. ideal s r::oction to pign;eatthe length of oma pgn:zntis present cannot bz guamnmzJ In some vasa, `piamm�; u ill be
<br />permanent
<br />I agree to release
<br />and Inrz�ar discharge. and hold hamdass, the Teehnidan, all employees, contractors, and the management of the pznnanam ttwke-up
<br />sn:du Cmm any and all ela:ms of negligence. damages, or legal actions as Bina from or connected In an} wn} with my 13uo4 the procedure, and conduct aved in my
<br />tattoo, and a m
<br />suc all responsbdiry for the decision(s) made consenting to this pommncnt procedure
<br />I am aware that permanant cosmetic inks, dyes, and pigmcots base not been approtedf b) the fedi n l Food and Drug, Administration and that the health
<br />consequences o f ueing these product; are unknown -
<br />I acknonviedue infection is always possible result of perrnane t Ap apt ][IcaL10
<br />n I have mce;vzrf pre- and post -pro • instmcuons and I
<br />undo t rid til rd ill to fly adh to such t tt f 1 nderstand that y f ' I m d :ay Jeopard ze my chances for a successful procedure, I 'e that it
<br />is ms responsibility to contact my Technician ref there are any signs and symptoms of infection, including bin nm limited to redazss swelling taudzrn... of 0
<br />he
<br />procedure sits, red sneaks gmng from the procedure sitz towards the bean, elevated body temtcoutue, or purulent drainage from rhe procedure site
<br />_ I undersand that the taking of before and aCie r photographs of the said procedure are a condition 0 such toedurn I release all nphis to any photographs
<br />taken is me and the permanent makeup and mire consent in advance to ibis pennanan; make-up studio to use images of m} taroo(s) for marke t Lie and, or publishma
<br />purposes in various media such as rhe in tem et. magazine, primed, and or television eta `
<br />_ I understand that if I have env sku: treatments, laser hair removal, plastic surgery or orb our skin altering procedures, it may result in ads
<br />ersc change; to m}
<br />pennanznt cosmetic;. I acknowledge some. of these potential adverse changes may not bz cortzctablz.
<br />. lain not pregnant or nursing. I do not have any history of hzryes infection at the proposed procedure site Ida not have epilepsy. diabz:zs,
<br />allergic rzanion
<br />to latex or antibiotics, hemophilia or other bleeding disorder I do not have cardiac rah c disease or suffer &om. any hewn conditions or take medications that thins mr
<br />blood.
<br />ICI suffer from hepatifis, or other risk factors for btoodbome pathogen exposure, or any other cnrnrrmnic
<br />Cast d hbdvised f tions
<br />able disease, I have informed the Technician of Cie
<br />anate een aoany medicaand procedure. necessary to promote the satisfaction healing, o(my tattoo -
<br />1 do not suffer from any medical a skin conditions) such as, but not Iimi ted 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 />[ do no: have a history of medication use or currently using medication, including being Prescribed antibiotics poor to dental or surgical procedures. If I am
<br />on any medication for depression or any other mood altering prescription
<br />, [will advise. my Technician.
<br />PLEASE COMPLETE BOTH THE FRONT AND BACK SIDE OF TFIIS CONSENT
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