Permanent Cosmetic Consent Form

Permanent Cosmetic Consent Form

Referred by

Date *

Date

Name *

Date of Birth *

Email Address *

example@example.com

Home Address

City, State

Zip

Cell Number *

Work Number

Are you currently under the care of a physician for any reason?

Yes No

If yes, please explain

Eyeliner Appointment: Do you have contacts in your eyes today? If so, please take them out before we start your eyeliner appointment. (This is for when we are doing eyeliner only.)

Yes No

Lip Appointment: Do you get fever blisters?If so, you will need to start a preventative medication today! See aftercare sheet attached!

Yes No

I give my permission for Lash Out Salon to use my photograph for promotional purposes. Please sign if Yes. Lash Out Salon will show cosmetic area only if you let Sierra know.

Clear

If you must cancel or postpone your follow up appointment, please give a 48-hour notice and remember it may be up to 8 weeks before you are able to get back on the schedule. There will always be a charge for a third application unless otherwise told to you by Lash Out Salon. If you feel that you need to have a third application after your touch-up appointment, to make changes, there may be a set up-charge fee of $75. This needs to be done within 2 months of your last appointment or the charge will be a touch up price of $275. Lips may require a third application to achieve your desired color. A $300 fee always applies.

Patient Signature

Clear

If you have or have ever had the following, please choose Yes or No.

Cold Sores, Herpes Simplex, Fever Blisters? If yes, you will need to get on a preventative medication. See post instruction sheet. If you have ever had any of these conditions, you will get it again with lip color. If you have chronic dry lips, you will need a note from your doctor to have lip color or liner. The constant peeling may or may not fade your lip color, so please be aware.

Yes No

Alopecia, Trichotillomania?

Yes No

Diabetes?

Yes No

If yes, is it under control or being treated?

Dry eyes, Glaucoma, Eye Surgery or any injury in the last 3 months?

Yes No

High Blood Pressure or an Abnormal Heart Condition?

Yes No

Hepatitis, HIV?

Yes No

Epilepsy?

Yes No

Currently Pregnant or Nursing?

Yes No

Are you allergic to any of the following?

Antibiotic Ointment, Baby Oil, Coconut Oil, Grapeseed Oil?

Yes No

Lidocaine, Benzocaine, Tetracaine?

Yes No

Baby Wipes?

Yes No

Saline?

Yes No

Signature

Clear

Date

Please let me know if you have any conditions that are not listed and make sure to ask me any questions you may have.

Informed Consent Tattooing/ Microblading/ Derma-pigmentation

I acknowledge by signing this agreement that I have been given full opportunity to ask any and all questions I might have about obtaining derma-pigmentation, tattooing, and/or microblading by Sierra Scales and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the fact and matters set forth below:

I understand that there is a risk of infection anytime the skin is broken, particularly in the event that I do not take proper care following my treatment. I agree to follow al1 instructions concerning after care for 1O days while the skin is healing. Other risks involved with the procedure may include, but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction(s) to products applied during and after the procedure, fanning or spreading of the pigment (pigment migration), fading of color and other unknown risks.

I have been told that there is a chance I may experience a corneal abrasion. I realize that variations in color and design may exist. I understand that if my skin color is dark, the colors will not appear as dark as they do on light skin. I understand that a "follow-up" appointment is recommended, and with some procedures more than one "follow-up" visit may be recommended. I agree to return for the "follow-up" visits recommended for me.

I acknowledge that this will be a permanent change to my appearance, and that no representations have been made to me as to the ability to remove pigment. To my knowledge, I do not have a physical, mental, or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have any derma-pigmentation, microblading, and/or tattooing at this time.

I acknowledge that obtaining derma-pigmentation, microblading, or tattooing is my choice alone. I consent to the application and to the actions that representatives of Lash Out Salon and Sierra Scales deem reasonably necessary to perform my procedure(s), and I understand that no guarantees have been made to me as to the results of the procedure.

Sierra Scales does not recommend lip enhancement (tattooing outside of the natural lip line), and I acknowledge that if I request this procedure, I am proceeding against the professional judgment of Lash Out Salon and Sierra Scales.

I acknowledge that I have been truthful to Sierra Scales and Lash Out Salon that this information is true and correct.

I agree to release and forever discharge and hold harmless Lash Out Salon, Sierra Scales and its representatives from any and all claims, damages, or legal actions arising from or connected with this procedure in any way. I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any unknown reason associated with the procedure planned for me.

Signature

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Date