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STATEMENT OF CONSENT AND RECITALS: <br /> Please read and initial all lines. <br /> Aftercare instructions have been explained to me and a written copy will be given to me to retain in <br /> my possession,which I will follow to the best of my ability. If I have questions I will call or email you. <br /> �I understand that a certain amount of discomfort is associated with this procedure and that swelling, <br /> redness and bruising may occur. <br /> _Fever blisters may occur in lip procedures in individuals who have the herpes simplex virus and it is <br /> my responsibility to obtain a prescription from my doctor for an anti-viral medication to help avoid a <br /> breakout. <br /> ,I understand that Retin A, Renova,Alpha Hydroxyl and Glycolic Acids must not be used on the <br /> treated areas. They will alter the color. <br /> �I understand that sun,tanning beds, pools,some skin care products and medications can affect my <br /> permanent makeup. <br /> _I understand that successful lip color saturation can NOT be guaranteed due to hidden scar tissue. <br /> _I will tell all skin care professionals or medical personnel about my permanent makeup procedures, <br /> especially if I'm schedule for an MRI. <br /> �I accept the responsibility for explain to you my desire for specific colors,shape,and position for any <br /> procedure done today. <br /> _I understand that implanted pigment color can slightly change or fade over time due to <br /> circumstances beyond your control and I will need to maintain the color with future applications and a <br /> touch up session within 60 days. <br /> _I acknowledge that the proposed procedure(s)involve risks inherent in the procedure and have <br /> possibilities of complications during and/or following the procedures such as: infection, misplaced <br /> pigment, poor color retention and hyper-pigmentation. <br /> _I have been quoted the cost of today's appointment which does not include touch up. <br /> I accept full responsibility for the decision to have this cosmetic tattoo work done. <br /> I certify that I have read or have had read to me the contents of this form. I understand the risks and <br /> alternatives involved in this procedure(s)and I have had the opportunity to ask questions and all of my <br /> questions have been answered. I acknowledge that I have reviewed and approved the material given to <br /> me and I authorize Her Brows by Ludda,as my permanent cosmetics technician to perform on my body <br /> the following procedures. <br /> Signature Date <br /> 4 <br />