COMPLIANCE INFO_TERI EISERT - Laserfiche WebLink

Home Browse Search

2T Are yQu tanned now in the A you want your prdcedure done? N 28. Any surgeries? Y N ` 29.Planning cosmetic surgery? Y N 30. Currently under a doctor's care for any particular condition? Y N Doctor's name, address,phone: 31. Trichotillomanioa (compulsively pulls out lashes,brows, and other hair which grows out of the body.)... Y N 32.Brow or lash tinting? Y N ...When was last time? 33. Contact lenses? Y N ...Please remove prior to procedure. 34. Alopecia Y N .....Do you have areata or universalis? 35.Have you tested positive for HIV? Y N 36. Are you claustrophobic Y N C. The Releasee agrees to waive or to take a 1-7 day scratch test prior to the permanent cosmetic facial tattoo procedure in order to determine allergic or other reaction to the applied pigment(s) and to detect fading or changes in the applied pigment(s). Initial to waive Initial to take patch test D. The Releasee agrees to accept frill responsibility for the color, shape, and thickness of each and every procedure that the Releasor will have performed by the Releases which is to include but not limited to the eyeliner,eyebrows,lips, and/or beauty mark permanent cosmetic procedure(s). E. The Releasee agrees that in the event of a controversy between the Releasor and the Releasee involving a claim in tort, the parties shall resolve their dispute through small claims court. The Releasor certifies that he or she has read the following provisions of the California Civil Code Section 1542: "A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release,which if known by him must have materially affected his settlement with the debtor". F. The Releasee acknowledges receipt of pro-procedure information and post-op care instructions, has read them, has been verbally told them, understands them, and agrees to adhere to them in order to help prevent secondary infection. 2. CONSENT TO PERMANENT COSMETIC PROCEDURE I fully and voluntarily consent to have the Releasor perform the permanent cosmetic procedure(s) and is fully aware and informed of all and any inherent risks, dangers, and complications that may occur as a result of the procedure(s)as described in this agreement. The Releasor has reviewed the medical history of the Releasee and all questions of the Releasee have been satisfactorily answered by the Releasor. Permanent cosmetics is not an exact science. Everyone has a different genetic makeup. We promise as micro pigment specialist to saturate the skin with pigment; it is up to your genetic makeup how much pigment your skin holds. For example, if you bleed during the procedure, the blood could push out the pigment. After the procedure has healed,it could look patchy. This can easily be taken care of on a follow up appointment at least one month after date of procedure. One of the reasons for the bleeding could be from taking aspirins, or high blood pressure medication. That is why we offer a follow up appointment free of charge if needed The follow up appointment is to correct anything that didn't hold The follow up appointment is not to make the color darker, change a color, or make eyeliner thicker. This is why a good consultation is so important The permanent cosmetics oxidize 40% darker by the time you leave the office. The permanent cosmetics will lighten within three to five days. The skin will flake off in this time period and the color will be under. A permanent cosmetic is a procedure; it has to be dark at first to get the desired color or outcome. It is very important that you follow the after care instructions and use the after care ointment that has been recommended. If you have any questions,please call us at(916)784-6226 1 Please