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I , , am 18 years of age or older, and as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure . You have described the recommended procedure to be used as Permanent Makeup , the process of implanting micro insertions of pigment into the dermal layer of skin . Permanent Makeup is a form of tattooing and the markings are permanent . I understand that there are no tattoo or permanent makeup pigments that have been approved by the Federal Food and Drug Administration . The health consequences of using these products are unknown . I voluntarily request as my intradermal cosmetic technician Cynthia Vasquez and such association and technical assistance as she may deem necessary to perform on my body the following procedure ( circle one ) : UPPER EYELID LOWER EYELID LOWER MUCOSAL EYELID EYEBROW FULL LIP COLOR LIPLINER AREOLAS SCAR CAMOUFLAUGE STRETCH MARKS OTHER : PLEASE INITIAL : I hereby authorize Cynthia Vasquez to take photographs/video of the work performed both before and after treatment , and I further authorize the use of said photographs to be used for the purpose of advertising . I have informed Cynthia Vasquez that I am in good health and not under the care of any Physician . I am currently under the care of a Physician and I am being treated for the following conditions : Physician 's Name : Phone Number : Address : City/State : zip : Please Initial : I have been given a copy of after care and acknowledge that failure to follow instructions may result in loss of color, discoloration , infection , etc . I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results . losur I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments . I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment . Disclosure and Consent for Permanent Cosmetics ( continued ) . . . However, spot testing does not identify individuals who may have a delayed reaction to pigment . I agree to ( circle one) : 2