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Permanent Cosmetics <br />Name:___________________________________ Date: ___________________ <br />Address: _________________________________________________________ <br />City, State, Zip:____________________________ DOB: __________________ <br />Home or Cell #: ___________________________________________________ <br />Email Address:____________________________________________________ <br />I, , am 18 years of age or older and as a client have <br />requested that you describe the procedure to be utilized so that I may make an <br />informed decision whether or not to undergo the procedure. <br /> You have described the recommended procedure to be used as <br />Permanent Makeup, the process of implanting micro insertions of pigment into the <br />dermal layer of skin. Permanent Makeup is a form of tattooing, and the markings <br />are permanent. <br />I understand that there are no tattooing or permanent makeup pigments that <br />have been approved by the federal Food and Drug Administration. The health <br />consequences of using these products are unknown. <br />I voluntarily request as my intradermal cosmetic technician, _____________ <br />and such association and technical assistance as she may deem necessary to <br />perform on my body the following procedure (circle one): <br />UPPER EYELID LOWER EYELID LOWER MUCOSAL EYELID <br />EYEBROW FULL LIP COLOR LIPLINER AREOLAS <br />SCARCAMOFLAUGE STRETCH MARKS OTHER:__________________ <br /> <br />Please Initial: <br />____________I hereby authorize ______________________ to take photographs <br />of the work performed both before and after treatment, and I further authorize the <br />use of said photographs to be used for the purpose of advertising. <br />318 E Yosemite Ave, Manteca Ca 95336 <br />info@thespaonyosemite.com <br />209-665-7168