Permanent Makeup Informed Consent

Permanent Makeup Informed Consent
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
The nature and method of the proposed permanent cosmetics procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur.

By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:

(Please mark YES after you clearly understand each statement)
I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible *

Yes
I acknowledge that complications as a result of permanent cosmetics procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications *

Yes
I realize that my body is unique and neither The Archery nor its employees or contractors can predict how my skin may react as a result of the procedure. *

Yes
I have previously had permanent cosmetics performed by someone other than The Archery on the same area (brows, lips, etc) that I am asking The Archery to work on today. *

Yes No
If YES to above, I understand that correcting or touching up permanent cosmetics that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which The Archery has no control. I understand that additional appointments after the initial and followup appointments may be required, and will be billed at The Archery’s standard rates. I understand that The Archery can not predict the results in advance and can not guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold The Archery harmless from same. *

Yes
I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. *

Yes
I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my permanent cosmetics, and that I must inform any future service provider that I have had permanent cosmetics applied. I understand and accept that such changes are not the fault of The Archery or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further permanent cosmetics procedures. *

Yes
I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance *

Yes
I acknowledge that obtaining the permanent cosmetics is my choice alone. I consent to the procedure and to its attendant risks, and to any actions or conduct of The Archery and its employees and contractors reasonably necessary to perform the procedure *

Yes
I understand that I will have the opportunity, within the time constraints of my appointment, to approve the design and color of the permanent cosmetics to be applied, and I accept responsibility for same. *

Yes
I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of The Archery. *

Yes
[Optional/Requested] I consent to The Archery using “before & after” photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting The Archery, which will then discontinue use of said photo(s) *

Yes No
I have been given the full opportunity to ask any and all questions which I might have about obtaining semipermanent cosmetic procedures from a permanent cosmetics specialist at The Archery and that all of my questions have been answered to my full and total satisfaction. *

Yes
If you have had previous permanent cosmetics performed by The Archery, has your medical history changed since you last filled out The Archery's Medical Profile form? *

Yes No
If YES, Please Specify.
I understand that there are no refunds on services rendered, including all permanent cosmetic procedures, at The Archery. *

Yes
Confidential Medical ProfileTo Avoid Unforeseen Complications, Please Answer The Following Questions
Please list any known allergies: *
Including adhesives, glues, tapes, bandaids etc. or N/A
Are you under 18? *

Yes No
Have you ever had any permanent cosmetics procedures before? *

Yes No
Do you wear contact lenses? (if yes, i understand they must be removed during my eyeliner procedure and should not be replaced until the next day) *

Yes No
Are you allergic to any metal? *

Yes No
Have you had any aspirin or blood thinners in the past week? *

Yes No
Do you have a history of cold sores, herpes, or fever blisters? *

Yes No
If yes, are you currently taking a RX for it? *

Yes No
If so, for how many days?
Are you allergic/sensitive to latex? *

Yes No
Is there any history of skin disease or remarkable skin sensitivities? *

Yes No
Have you had a chemical peel or laser? *

Yes No
If so, when?
Are you currently taking any vitamins A or E in any form? *

Yes No
Do you have problems healing? *

Yes No
Are you pregnant or nursing? *

Yes No
Are you currently undergoing radiation or chemotherapy? *

Yes No
Are you required to take antibiotics during dental or invasive medical procedures? *

Yes No
Are you currently using any retin-a or alpha-hydroxy skin care products? *

Yes No
Previous problems with tattoos or has your physician advised you not to have a tattoo at this time? *

Yes No
Any mood altering drugs within the last 8 hours? *

Yes No
Are you on any immunosuppressive medications such anti-inflammatories or steroids? *

Yes No
List all medications you are currently taking: *
N/A if none
Type a question

Heart Conditions Allergies to Make Up Accutane Treatment Sensitive Skin Diabetes Stroke Chest Pains Alopecia Tendency to Bleed excessively from minor injuries Sunburn in the area to be treated Breakout/Acne in the area to be treated Keloid/Hypertrophy of Scars Epilepsy/Seizures Shortness of Breath Autoimmune Disorder Cancer (Any) Hepatitis/Jaundice HIV Kidney Disease Rosacea Claustophobic HyperpigmentationHypopigmentation Fever Hyperpigmentation/Hypopigmentation Tendency to bruise easily Problems numbing with the dentist Have trouble sitting still
List any other medical conditions or issues not addressed above: *
N/A if none
Primary Physician's Name: *
Primary Physician's Phone Number: *
By signing below, I acknowledge, understand and agree that:

The staff at The Archery do not practice medicine, does not accept health insurance, and have made no representation to the contrary.
The information provided on this form is accurate and complete to the best of my knowledge, and that The Archery is not responsible for complications or problems arising from any incorrect or omitted information;
Some individuals will have complications related to permanent cosmetics. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold The Archery and its employees and contractors harmless for same;
The staff at The Archery will use the information provided above to assess my suitability for the proposed permanent cosmetics services.
24- hour notice is required for any canceled or rescheduled appointment or 50% of service price will be charged. Failure to show without notice will require in full payment of service booked. The Archery does not offer monetary refunds on services rendered. We do have a 7-day policy in place on services in which a client can come back and have corrections made. Fees may apply. By initialing here, I’m acknowledging I have read and understand the terms of these policies *

Yes
Signature *

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Permanent Makeup Informed Consent

Confidential Medical ProfileTo Avoid Unforeseen Complications, Please Answer The Following Questions