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Flawless Studios by Nicholette Vonmakle 9210 Thornton Road Stockton (209)407-7274 COSENTTO APPLICATION OF PERMANENT MAKEUP PROCEDURE NAME DATE DOB ADDRESS CITY STATE 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 procedure. The general natural of permanent cosmetic as well as the specific procedure to be preformed has been explained to me. PROCEDUR # OF PROCEDURE VISIT: # OF FOLLOW-UP VISIT: COST OF PROCEDURE(s): I understand that correction procedure are charged on a per visit basis. The number of visit cannot be determined at the time of first treatment. Client has no patiently allow at at least 6-8 weeks healing time to determine if additional procedure(s) are needed (initial) 1 understand that once the preview of the procedure is approved by me, there will be no refund giving after the procedure is completed. (initial) I have been informed of the nature, risk, and possible complications and consequences of the permanent skin pigmentation. I understand the permanent skin pigmentation produce carries with know and unknown complication and consequence associated with this type of cosmetic procedure, including, but not limited to: infection, scarring, inconsistent color and spreading, fanning or fading of pigments. I understand the actual color of pigment of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is permanent cosmetic process and therefore not a exact science, but an art. I request the permanent skin pigmentation procedure(s), and accept permanence of the procedure as well as the possible complication and consequences of the stated procedure(s). (initial) There is a possibility of an allergic reaction to the pigment. A patch test is advisable however it does not ensure clients will not have a allergic reaction. I consent (initial) and wave (initial) the patch test. If waved, I release the technician from liability if I develop an allergic reaction pigment. I understand that if I have any skin treatment, laser hair removal, plastic surgery or other skin procedure, it may result in adverse change to my permanent cosmetic, I acknowledge some of these potential adverse changes may not be correctable (initial) I have received pre and post procedures instructions and I will strictly advise to such instructions. I understand that me failure to do so may jeopardize my chance of successful procedures(s). If I am on any medications for depressions or any other mood alternative prescriptions, I will advise my technician. (initial) I understand that taking before and after photographs of the start procedure(s) are a condition of such procedure(s). I certify I have read and initialed all above paragraphs and have had to explain to my understandings thus consent procedures permit. I accept full responsibility for the decisions to have this cosmetic procedure(s) work done. (initial) understand I will have permanent make-up applied using appropriate instruments and sterilization techniques. I understand that the permanent make-up site usually takes 2 weeks or longer to heal. 1 agree to release and forever discharge and hold harmless the technician, all employees, contractors, and the management of the permanent make-up studio from any and all claims of none negligence, damages or legal action arising from or connected in a way with my permanent make-up, the procedures, and conduct used in my permanent cosmetic and assume all responsibility for the decision(s) made consenting to this permanent procedures) (initial) CLIENT SIGNATURE: TECHNICIAN: