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COI*ENT TO APPLICATIOW OF <br /> PERMANENT MAKEUP PROCEDURE <br /> Client Name: <br /> Last First Middle <br /> Date of Birth (MM/DD/YYYY) Gender: Phone: ( ) <br /> Address: <br /> Driver's License Number(Required): A photocopy will be retained in your file. <br /> Emergency Contact Name: Phone: ( ) <br /> I, am over the age of 18, am not under the influence of drugs or alcohol. <br /> am not pregnant or nursing and desire to receive the below indicated permanent cosmetic procedure(s). The general <br /> nature of cosmetic tattooing as well as the specific procedure(s) to be performed has been explained to me. <br /> X_ <br /> Client Initials <br /> Procedure(s): <br /> Number of Visits Required: Cost of Procedure(s): $ <br /> I have been informed of the nature,risks,and possible complications and consequences of permanent skin pigmentation. <br /> I understand the permanent skin pigmentation procedure(s) carries with it known and unknown complications and <br /> consequences associated with this type of cosmetic procedure(s), including but not limited to: infection, allergic <br /> reaction, scarring, inconsistent color, and spreading, fanning , fading of pigments. Corneal abrasions are a rear side <br /> effect, especially if I rub or itch my eyes or apply contacts too on after any eyeliner procedure(s). I understand that <br /> actual color of pigment may be modified slightly,due to the tone and color of my skin. I fully understand this is a tattoo <br /> process and therefore not an act of science, but an art. I request the permanent-skin pigmentation procedure(s), and <br /> accept the permanence of the procedure(s) as well as the possible complications and consequences of the said <br /> procedure(s). Also, I have been notified that inks are not FDA approved and health consequences unknown. <br /> X <br /> Client Initials <br /> I understand that if I have any skin treatments,laser hair removal,plastic surgery or other skin altering procedure(s),it <br /> may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may <br /> not be correctable. X <br /> Client Initials <br /> I have received pre and post procedure(s) instructions and I will strictly adhere to such instructions. I understand that <br /> my failure to do so may jeopardize my chances for a successful procedure(s). If I am on any medication for depression <br /> or any other mood altering prescription, I will advise my technician. If I have ever had cold sores/Herpes simplex, I will <br /> consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure(s) <br /> around my lips. X <br /> Client Initials <br /> I understand that taking before and after photographs of the said procedure(s) are a condition of such procedure(s). <br /> X <br /> Client Initials <br /> I certify 1 have read and initialed the above paragraphs and have had explained, to my understanding,this consent <br /> and procedure(s)permit 1 accept full responsibility for the decision to have this cosmetic tattoo work done. <br /> Client: Date: <br /> Technician: Date: <br /> L <br />