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L0 Lr) <br /> rn <br /> d�a��. tt�' Admanenakeup o <br /> tM <br /> N N <br /> L0 rd" <br /> 01� il� � ":,r m <br /> rz � � % irj Informed Consent Form a <br /> er�at�► etpl r�� I, am over the age of la,am not under the innuenre of drugs or <br /> alcohol am not permanent pigmentation pregnant or nursing and delve to receive the indicated prgm PM'edmre. <br /> The general nature of cosmetic micro-pigmentation,as well as the specific procedure to be performed,has <br /> been explained to me. <br /> rc• a i� <br /> f hereby authorise perform upon myself the <br /> fmnowfngpmredure(s) „c <br /> =t <br /> lfanY unforeseen condition arises inthe course ofNS procedure(s),calling in her judgement in <br /> addition to,or different from those now contemplated,I further request and authorise her to do <br /> whatever she seems advisable and necessary in the circumstances. <br /> I accept responsibility for determining the colour,shape and position of the permanent <br /> cosmetic procedure as agreed during the course of my consultation. <br /> I understand that an allergy test does not guarantee that I will not have an allergic reaction to <br /> the pigment. <br /> We =or accept responsibility if the treatment area does not numb.Each individual is <br /> different according to the skin type.For all procedures a cream or gel topical anaesthetic is used. <br /> These products are perfectly safe,and can be purchased over the counter from any chemist <br /> I fully understand and accept that non-toxic pigments are used during the procedure and that <br /> the cosmetic enhancement achieved may fade over a period of 1-3 years.Even though the colour <br /> has faded the pigment will stay in the skin indefinitely. <br /> For eyeliner procedures you will be asked to keep your eyes closed throughout the numbing <br /> period.If for some reason the anaesthetic gets into the eye,you must advise your technician at <br /> � once.It not harmful to the eye althou ou will <br /> 0 <br /> N is $h y experience some stinging and slight <br /> `o discomfort The cream vnll be removed and your eyes will be immediately hushed with a sterile <br /> 0) <br /> U saline solution It is then safe for the technician to reapply the anaesthetic.NOTE:If you <br /> o experience stinging in the eyes and do not inform your technician immediately,the anaesthetic <br /> may numb the eyeball,and a possible corneal abrasion may occur.This can result in a temporary <br /> g streaming and light sensitivity of the eyes.You may be unable to open your eyes and each bme <br /> U <br /> you blink it may be painful,and temporary blurry vision may occur.Corneal abrasion,however, <br /> * is rare. <br /> a) <br /> I understand that the Permanent Make-Up Inks used in my procedure are NOT FDAApproved. <br /> J <br /> L <br /> U <br /> I have been informed that the highest standards of hygiene are met and that sterile disposable <br /> LU E needles and pigment containers are used for each individual client,procedure and visit. <br /> r <br /> r � <br /> N +� <br /> a�l a I understand and accept that each procedure is a process requiring multiple applications of <br /> pigment to achieve desirable results,and that 100%success cannot be guaranteed during the rn <br /> CN <br /> first procedure,I understand that this is why Iwill need to return for a retouch procedu e, w <br /> a) N <br /> N L O to <br /> Q) d <br /> m U �_ <br /> L N 0 <br /> = C <br /> 0 (n n. to <br />