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CONSENT TO APPLICATION OF <br /> PERMANENT MAKE-UP PROCEDURE <br /> NAME. DATE DOB <br /> ADDRESS CITY <br /> STATE ZIP HOME PH. WORK PH. <br /> I, am over the age of 18,am not under the influence of drugs or <br /> alcohol and desire to receive the indicated permanent cosmetic procedure. The general <br /> nature of cosmetic tattooing as well as the specific procedure to be performed has been <br /> explained to me. X <br /> PROCEDURE(s): <br /> NO. OF VISITS REQUIRED: <br /> COST OF PROCEDURE(s): <br /> I understand the permanent skin pigmentation procedure carries with it possible <br /> complications and consequences associated with this type of cosmetic procedure, <br /> including but not limited to: infection, scarring, inconsistent color, and spreading,fanning <br /> of fading pigments. I understand the actual color of the pigment may be modified slightly <br /> due to the tone and color of my skin.. I fully understand this is a tattoo process and <br /> therefore not a science but an art. I request the permanent skin pigmentation pmcedure(s), <br /> and accept the permanence of the procedure as well as the possible complications and <br /> consequences of the said procedure(s).Notice that inks are not FDA approved and health <br /> consequences are unknown.X <br /> I will strictly adhere to all pre-and post procedure instructions. If I ever had cold sores,I <br /> will consult with and strictly follow my doctor's instructions before contemplating any <br /> permanent cosmetic procedure around my lips.X <br /> I understand the taking of before and after photographs of said procedure(s)are required. <br /> I certify I have read and initialed the above paragraphs and have explained to my full <br /> understanding this consent and procedure permit. <br /> CLIENT: DATE <br /> TECHNICIAN: DATE <br /> Received Time Aug, 1. 2015 5: 33PM No- 1332 <br />