COMPLIANCE INFO_TERI EISERT - Laserfiche WebLink

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INFORED CONSENT TO PERMANENT C METICS Name: DOB: Address: City: Zip: e-mail: phone#: PLEASE READ AND INITIAL ALL STATEMENTS, AND CONCERNS BELOW REGARDING YOUR PROCEDURE WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS In consideration of receiving permanent cosmetics from the Certified Permanent Cosmetic Technician at Kharma Spa and Salon, Teri Turrentine-Eisert CPCT, I, confirm the following statements by initialing each item below: I state that I am, in fact,the person stated above and I am at least 18 years of age. All questions have been answered to my satisfaction, by the technician herself. I have discussed my desired shape and color tone regarding the specific said procedure and have full confidence that the technician is aware of what I am requesting. I understand that tattooing of any form, can only be removed via laser by a licensed physician, and not by the cosmetic technician, and that there is a high possibility of scarring and remaining pigment fragments. I understand that should I ever choose to have my tattoo removed, it will be done so at my expense. I am not under the influence of illegal drugs or alcohol, and any medication I am on will be noted on the medical history questionnaire on the back of this form. I am voluntarily submitting to be tattooed without duress or coercion. I understand that there is a possibility of allergic reaction that would be of no fault of the technician. I understand that there is a possibility of getting an infection that would be of no fault of the technician or even myself, but from the environment where I work, live,or visit. I agree to follow all instructions that are recommended from the technician,Teri Turrentine-Eisert concerning the care of my tattoo. I understand that there will be only one touch up included with the initial procedure,and any afterwards will be at my own expense. I understand that there is pain involved with this procedure and that the technician uses a topical numbing cream to ease the pain, however, I may feel a slight burning sensation from the cream itself. I agree to immediately notify the technician in the event I feel lightheaded,dizzy or nauseous directly before, during,or immediately following the procedure. I understand that tattooing in any form, is an art and not a science,and therefore, slight imperfections may exist in the healed tattoo, however, I am trusting in the abilities and experience of the technician to make sure that they are minimal, if any at all,and can be corrected and perfected in the touch up offered to me. have been informed of all risks, including, but not limited to, infection,scarring, allergies to pigment, lidocaine,tetracaine, latex, nitrile, and antibiotics. The Federal Food and Drug Administration has not approved tattoo inks, dyes,or pigments for use,and the health consequences of using these products are unknown, if there any at all. Having been informed of all potential risks associated with giving a tattoo, I still wish to proceed with the application, and I assume any and all responsibilities that may arise. Signed: Date: ARTIST or TECHNICIAN USE ONLY: Disposable Tube Type Lot# Disposable Needle Size Lot# Pigment Color