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)