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0. <br /> INFORMED CONSENT FORM <br /> THE NATURE AND METHOD OF THE PROPOSED PERMANENT MAKEUP (COSMETIC TATTOO) <br /> PROCEDURE HAS BEEN EXPLAINED TO ME BY TANTRA INK HPM, INCLUDING THE USUAL RISKS <br /> INHERENT IN THE PROCEDURE PROCESS, AND THE POSSIBILITY OF COMPLICATIONS DURING OR <br /> FOLLOWING THE PERFORMANCE. I UNDERSTAND THERE MAY BE A CERTAIN AMOUNT OF <br /> DISCOMFORT OR PAIN ASSOCIATED WITH THE PROCEDURE AND THAT OTHER ADVERSE SIDE <br /> EFFECTS MAY INCLUDE MINOR AND TEMPORARY BLEEDING, BRUISING, REDNESS OR OTHER <br /> DISCOLORATION AND SWELLING. FEVER BLISTER MAY OCCUR ON THE LIPS FOLLOWING LIP <br /> PROCEDURES IN INDIVIDUALS PRONE TO THIS PROBLEM. FADING OR LOSS OF PIGMENT MAY <br /> OCCUR. SECONDARY INFECTION IN THE AREA OF THE PROCEDURE MAY OCCUR, HOWEVER IF <br /> PROPERLY CARED FOR, IS VERY RARE. <br /> • I ACKNOWLEDGE THAT HYPER-PIGMENTATION (DARKENING OF THE SKIN) OR HYPO- <br /> PIGMENTATION, (ABSENCE OF COLOR IN THE SKIN), OR SCARRING IS A POSSIBILITY AS A <br /> RESULT OF MY BODY'S REACTION TO THE SKIN BEING BROKEN DURING THE PROCEDURE. I <br /> REALIZE THAT MY BODY IS UNIQUE AND PMU TECHNICIAN CANNOT PREDICT HOW MY SKIN <br /> MAY REACT AS A RESULT OF THIS PROCEDURE. <br /> • I UNDERSTAND THAT FUTURE LASER TREATMENTS OR OTHER SKIN ALTERING PROCEDURES, <br /> SUCH AS PLASTIC SURGERY, IMPLANTS AND INJECTIONS MAY ALTER AND DEGRADE MY <br /> PERMANENT MAKEUP. I FURTHER UNDERSTAND THAT SUCH CHANGES ARE NOT THE <br /> RESPONSIBILITY OF TANTRA INK HPM. I FURTHER UNDERSTAND THAT SUCH CHANGES IN MY <br /> APPEARANCE MAY NOT BE CORRECTABLE THROUGH FURTHER PERMANENT MAKEUP <br /> PROCEDURES. <br /> fflS�" 6( wroleS <br /> • I AM AWARE THAT THE HERPES ZOSTER I VIRUS (FEVER BLISTERS, OR COLD SORES) MAY <br /> MANIFEST WITH THE LIP PROCEDURE DUE TO TRAUMA TO THE LIP TISSUE. THE ANTICIPATION <br /> OF A HERPES ZOSTER L VIRUS BREAK-OUT MAY BE PRE-TREATED WITH ANTI-VIRAL <br /> MEDICATION, SOME OF WHICH ARE AVAILABLE BY PRESCRIPTION ONLY FROM YOUR <br /> PHYSICIAN. IF ELECTED AS A PROCEDURE I HAVE BEEN ADVISED. <br /> • I HAVE BEEN INFORMED THAT MEDICATIONS THAT I AM CURRENTLY ON MAY INTERFERE WITH <br /> THE DEPOSIT OF COLOR. TANTRA INK HPM WILL DEPOSIT 100% COLOR TO MY SKIN, DUE TO <br /> THE CHEMICAL MAKEUP OF MY SKIN OR DAMAGE FROM THE SUN, MY PERMANENT MAKEUP <br /> MAY NEED MULTI FOLLOW UP VISITS, WHICH WILL INCUR ADDITIONAL CHARGES TO DEPOSIT <br /> MORE COLOR IN MY SKIN. COST TO BE DETERMINED BY TANTRA INK HPM. <br /> • [ ACKNOWLEDGE THAT THE INKS USED FOR THE PROCEDURES SOT FDA APPROVED, AND <br /> HEALTH CONSEQUENCES ARE UNKNOWN. <br /> Signaturei?" Date <br /> 0.)203-601-1326 @TANTRAINK' YAHOO.COM t"dTA\TRAINK.HPki <br />