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C E CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDU1E NAME: ADDRESS: HOME/CELL PH.: EMAIL: CITY: TE DOB STATE: WORK PH. ZIP: I, am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated permanent cosmetic treatment. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. PROCEDURE(s): NO. OF VISITS REQUIRED: COST OF PROCEDURE(s): I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation treatment carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner treatment. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation treatment(s), and accept the permanence of the treatment as well as the possible complications and consequences of the said treatment(s). Initial There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. I consent (initial) or waive (initial) the patch test. If waived, I release the technician from liability if I develop an allergic reaction to the pigment.