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CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE <br />NAME DOB DATE <br />ADDRESS CITY <br />STATE ZIP CODE PHONE NUMBER <br />PROCEDURE <br /># OF VISITS REQUIRED COST OF PROCEDURE <br />I, am over the age of 18 and am not under the influence of drugs or <br />alcohol and desire to receive the indicated permanent makeup procedure. The general nature of <br />cosmetic tattooing as well as the specific procedure to be performed has been explained to me. <br />X <br />I have been informed of the nature, risks, and possible. complications and consequences of <br />permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries <br />with it known and unknown complications and consequences associated with this type of <br />cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, <br />inconsistent color, and spreading, fanning, or fading of pigments. I understand that the actual <br />color of the pigment. may be slightly modified, due to the tone and color of my skin. I fully <br />understand that this is a tattoo process and therefore not an exact science, but an art. I request the <br />permanent skin pigmentation procedures) and accept the permanence of the procedures) as well <br />as the possible complications and consequences of the procedure(s). X <br />I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin <br />altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge <br />some of these potential adverse changes may not be correctable. X <br />I have received pre- and post-procedure instructions and I will strictly adhere to such <br />instructions. I understand that my failure to do so may jeopardize my chances for a successful <br />procedure. If I am on any medication for depression or any other mood -altering prescriptions, I <br />will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my <br />doctor's instructions before contemplating any permanent cosmetic procedure around my lips. <br />X <br />I understand that the taking of before and after photographs of the procedures) are a condition of <br />such procedure(s). I certify that I have read and initialed the above paragraphs and have had <br />explained to my understanding this consent and procedure pernut. I accept full responsibility for <br />the decision to have this cosmetic tattoo work done. <br />CLIENT DATE <br />TECHNICIAN DATE <br />