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CONSENT TO APPLICATION OF <br /> PERMANENT MAKE-UP PROCEDURE <br /> Name: DOB: <br /> Address: <br /> City: State: Zip: <br /> Phone: Emergency Contact Phone: <br /> Micro pigmentation is the process of placing pigment into the dermis. This process is considered <br /> a tattoo. These pigments can last up to a few years, depending on skin tone and the intensity of <br /> the color that is used. Lighter skin tones will not hold the color as long as darker skin tones and <br /> may require an occasional touch-up to prolong the results of the procedure. <br /> *Touch-ups: The need for a touch-up varies from person to person. Touch-ups cannot be <br /> scheduled any sooner than four weeks following the previous procedure. The skin needs at least <br /> four weeks to completely heal and may need longer with elderly patients,health problems and/or <br /> smokers. There is a complimentary touch-up from 4 weeks after within 6 months of initial <br /> service (must have ink card present). <br /> Medical and Skin History <br /> Are you pregnant/nursing? Yes No <br /> Do you smoke? Yes No <br /> Do you wear contact lenses? Yes No <br /> (if yes,they must be removed for the eyeliner procedure) <br /> Do you have any allergies? Yes No <br /> (if yes,please specify: <br /> Do you have any tattoos? Yes No <br /> Have you ever had any permanent make-up procedures before? <br /> Yes No <br />