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First Name Last Na. Please read arid check each box: I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur. I understand that im planted pigment color may slightly change or fade over time due to circumstances beyond control and that I will need to maintain the color with future applications and a touch up session within 60 days. I r I am 18 years of age or older Possible Risks/Hazards/Complications: PAIN: There could be pain even afterthe topical an 'esthetic has been used. Anesthetics work better on some people than others, INFECTIONS: Infection is very unusual. Less than 0.25% of the population has an allergic reaction. The areas treated must be kept clean and onlytouched with freshly c eaned hands. See "After Care for Lip Blush" for Instructions. UNEVEN PIGMENT: This can be a result of poor healing, infeftlon, bleeding, or other causes. Yourfollow up appointment will likely correct any uneven appearances. ASYMMETRY: Every effortwill be made to avoid asymmetry, but our faces are asymmetrical and adjustments may be needed during the follow yup session to correct any unevenness. EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. Ittypically disappears within the first few days. ANESTHESIA: Topical anesthetics are used for numbing the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please Inform your technician immediately. MRI: Pigments used I i permanent cosmetic procedures contain Inert oxides; a low level magnet maybe required if you need to be scanned by an N RI machine. You must Inform your technician of any tattoos or permanent cosmetics. ALLERGIC REACTION: There is a small pc ssibility of an allergic reaction. You may take a 5-7 day patch test to determine this. Lip Specific Cautions: * Herpes Simplex Virus: If you have an outbreak, youlmust reschedule your appointment and wait until it has healed at least 6 weeks. If you have a history of cold sores, please asik your doctorfor an antiviral medication and take them 5 days before treatment and'.5 days after. Lip blushing can trigger cold sores) Hyperpigmentation: Most commonly seen In African, Caribbean, Mediterranean, Asian and Latin skin types. Understand thatthe risk of the procedure may cause hyperpigmentation but will be treated very carefully. Chapped Lips: Please follow the Pre -Care Instructions to exfoliate 1 week for everyday until appointment and hydrate. The lips must be a clean canvas for good pigment retention and healing. Lip Fillers: Must wait A weeks afterfillers before lip blushing procedure. r Yes, I have read and understand the possible frisks, hazards and complications. I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. I understand that im planted pigment color may slightly change or fade over time due to circumstances beyond control and that I will need to maintain the color with future applications and a touch up session within 60 days. I r I am 18 years of age or older Possible Risks/Hazards/Complications: PAIN: There could be pain even afterthe topical an 'esthetic has been used. Anesthetics work better on some people than others, INFECTIONS: Infection is very unusual. Less than 0.25% of the population has an allergic reaction. The areas treated must be kept clean and onlytouched with freshly c eaned hands. See "After Care for Lip Blush" for Instructions. UNEVEN PIGMENT: This can be a result of poor healing, infeftlon, bleeding, or other causes. Yourfollow up appointment will likely correct any uneven appearances. ASYMMETRY: Every effortwill be made to avoid asymmetry, but our faces are asymmetrical and adjustments may be needed during the follow yup session to correct any unevenness. EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. Ittypically disappears within the first few days. ANESTHESIA: Topical anesthetics are used for numbing the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please Inform your technician immediately. MRI: Pigments used I i permanent cosmetic procedures contain Inert oxides; a low level magnet maybe required if you need to be scanned by an N RI machine. You must Inform your technician of any tattoos or permanent cosmetics. ALLERGIC REACTION: There is a small pc ssibility of an allergic reaction. You may take a 5-7 day patch test to determine this. Lip Specific Cautions: * Herpes Simplex Virus: If you have an outbreak, youlmust reschedule your appointment and wait until it has healed at least 6 weeks. If you have a history of cold sores, please asik your doctorfor an antiviral medication and take them 5 days before treatment and'.5 days after. Lip blushing can trigger cold sores) Hyperpigmentation: Most commonly seen In African, Caribbean, Mediterranean, Asian and Latin skin types. Understand thatthe risk of the procedure may cause hyperpigmentation but will be treated very carefully. Chapped Lips: Please follow the Pre -Care Instructions to exfoliate 1 week for everyday until appointment and hydrate. The lips must be a clean canvas for good pigment retention and healing. Lip Fillers: Must wait A weeks afterfillers before lip blushing procedure. r Yes, I have read and understand the possible frisks, hazards and complications.