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PEPMRNENT COSNETICS CONSENT FORM <br /> Date: Driver's License#: <br /> Name.. Date of Birth: <br /> Address: City: State: <br /> zip: <br /> Home Phone: Cell: <br /> E-mail: <br /> If we call you at home, do you want confidentiality? <br /> YES /NO <br /> Emergency Contact: <br /> Phone#: Relationship <br /> Ethnic Background, please include all nationalities: (this <br /> information will help us choose the correct pigment color for <br /> your skin type) : <br /> Who may we thank for referring you? <br /> Procedure (s) Desired: Brows <br /> Clinical Outcome of Procedure (s) : <br /> 1. The results of your procedure is determined in part by the <br /> nature of the pathology of skin type, but not limited to the <br /> following factors: <br /> — Medication you are currently taking. <br /> — Skin characteristics: Dryness, oiliness, thickness, sun- <br /> damaged, color, chemically-damaged, etc. <br /> Natural skin undertones mixing with pigment color. <br /> Personal pH balance of skin, tanning booths, fruit acids, <br /> AHA's and Retin A use. <br /> — Alcohol intake, smoking, sun exposure and improper skin care. <br /> — Following Pre and Post instructions. <br /> — In some cases, these factors can or may interfere with <br /> acceptance fading of color pigment. <br /> Informed Consent Procedure: <br /> Initial <br /> 1. 1 absolutely understand and accept that the <br /> procedure is a process, often requiring a follow-up application <br /> of color to achieve desirable results and that 100% success <br /> cannot guaranteed. <br /> 2. 1 acknowledge that obtaining permanent makeup is my <br /> choice alone. The application Permanent makeup will result in a <br /> permanent change to my appearance, and that needles and pigments <br /> will go into my skin using only sterile disposable single use <br /> needles. No representations have been made to me as to the <br /> ability to later restore the skin involved in permanent makeup to <br /> the original condition, and can be costly to remove. <br /> 3. 1 understand that I will have permanent makeup <br /> using applied using instruments and sterilization techniques . I <br /> understand that the permanent makeup site usually takes 2 weeks <br /> or longer to heal. I agree to release and forever discharge and <br /> 1 <br />