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Name: Last Dame: Date: Address: City: State. Zip• Residential Phone: Alt. Phone: I am over the age of 18. I am not under the influence of drugs or alcohol, and I desire to receive the indicated cosmetic procedure (please circle): EYEBROWS - EYELINBR - LIP LINER - BEAUTY MARK COL$1N: COST-.— The OS .The general nature of permanent make-up cosmetics as well as the specific procedure(s) has been explained to me. • I understand the usual risks inherent in the procedure and the possibility of complications during and following, its performance. I understand there may be a certain amount of pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fever blisters may occur on the lips following lip procedures on individuals prone to this problem. Fading or loss of pigment may occur. Secondary infection in the procedure area rarely occurs. • I absolutely understand and accept that the i'IVIU Procedure is a process, often requiring multiple applications of color to achieve desirable results. • it is understood that I have the option of receiving a patch test prior to the procedure to detect allergic (or other) reaction(s) to the applied pigments. I agree to adhere to pre- procedure and post-procedure instructions. • Depending on the procedure(s) which I select, I accept responsibility for determining the color, shape, and position of the eyebrows, eyeliner, lip liner color, and/or the color of camouflage. • I understand the taking of before and after procedure(s) photos are required and may or may not be used for advertising. I've read the above paragraphs, and have been explained to my full understanding, this procedure consent. ® I understand this`procedure will result in a permanent nature of body art. + Inks, dyes and pigments have not been approved by the U.S. Food and Drug Administration (FDA), and the health consequence is not known, Please shack any of the following medical conditions that RRI High blood pressure Diabetes Allergies Heart problems Thyroid disease Skin cancer / Keloid skin Easily bruised Excessive bleeding Fever blisters / Herpes Hepatitis Currently pregnant Eye surgery or injury Cataracts «Diy eye" Corneal abrasions Currently wearing contact lenses If yes to any of the above please specify: List all medications you are currently taking: Client Signature: Date: (04/14)