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First Name Last Please read and check each box: Phone Number (_) I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur. r I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. r i understand that Implanted pigment colormIay slightly change or fade overtime 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 am 18 years of age or older Possible Risks/Hazards/Complications: PAIN: There could be pain even after the topical a esthetic has been used. Anesthetics work better on some people than others. INFECTIONS: Infection is very unusual. Less 0.25% of the population has an allergic reaction. The areas treated must be kept clean and only touched with freshly Gleaned hands. See "After Care for eyellner" for instructions. UNEVEN PIGMENT: This can be a result of poor healing, Infection, bleeding, or other causes. Your follow up appointment will likely correct any uneven appearances. ASYMMETRY: Every effort will be made to avoid asymmetry, but our faces are asymmetrical and adjustments may be needed during the follow up session to correct any unevenness. EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. It typically disappears within the first few days. ANESTHESIA: Topical anesthetics are used for numbing the area to be tattooed. Lidocalne, Prllocalne, Benzocalne, Tetracaine Epinephrine in a cream or qel form are typically used. If you are allergic to any of these please inform your technician immediately. MRI: Pigments used in permanent cosmetic procedures contain inert oxides; a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics. ALLERGIC REACTION: There is a small p Issibility of an allergic reaction. You may take a 5-7 day patch test to determine this. Medical History Questionnaire Have you had or currently have any of the following? Currently Pregnant Currently Breastfeeding Had history of Methicill Yes No r aureus (MRSA) i" i` Had undergone Botox treatment ' C f`