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rJ <br />CONSENT TO APPLICATION OF PERMANENT MAKEUP <br />PROCEDURE <br />NAME: <br />ADDRESS: <br />HOMEXELL PH.: <br />EMAIL: <br />CITY: <br />DATE DOB <br />STATE: <br />WORK PH. <br />ZIP: <br />I am over the age of 18, am not under the influence of drugs or alcohol, <br />am not pregnant or nursing and desire to receive the indicated permanent cosmetic treatment. The <br />general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained <br />to me. <br />PROCEDURE(s): <br />NO. OF VISITS REQUIRED: <br />COST OF PROCEDURE(s): <br />I have been informed of the nature, risks, and possible complications and consequences of permanent skin <br />pigmentation. I understand the permanent skin pigmentation treatment carries with it known and <br />unknown complications and consequences associated with this type of cosmetic procedure, including but <br />not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. <br />Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon <br />after any eyeliner treatment. I understand the actual color of the pigment may be modified slightly, due <br />to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact <br />science, but an art. I request the permanent skin pigmentation treatment(s), and accept the permanence <br />of the treatment as well as the possible complications and consequences of the said treatment(s). <br />Initial <br />