Cosmetic Tattoo Consent Form

Cosmetic Tattoo Consent Form

This is a legal document. Please read carefully.
Client Information
Full Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Phone Number*
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Consuming alcohol within 24-48hrs prior to appointment may lead to excessive bleeding thus affecting the healed result. Have you consumed alcohol within the last 24-48 hrs?

YesNo
FEMALE ONLY: Pregnant or Nursing?

YesNo
Do you have a communicable disease?

YesNo
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, etc.)
If yes, please identify the condition.
Are you currently taking any medication?
ie. ibuprofen, blood thinners, etc.
Medical History (e.g. Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Any known allergies?
metals, foods, etc.
Have you previously had semi permanent make up done?
If yes, machine or manual?
How did you hear about us?
If referred by someone, fill out below.
(If referred) Referred by:Name
Above is an example of brow-mapping. This as a guide to determine symmetry, arch location, size, and to create a natural design. All brows are tailored to suit individual face shape and client preference on length and thickness. When brows are pre-drawn by artist, know that it is a guide used for your intended tattoo shape thus the resulted color will be different. You will be asked a series of questions about your brow preferences during this time.
Acknowledgment and Waiver
I, CLIENT hereby consent to and authorize Kannith Meas-Truong (cosmetic tattoo artist) to perform the following procedure: BROWS / EYELINER / OTHER.
Driver’s license/ID number:
I have read and fully understand the following:*

I am at least 18 years of age.I have voluntarily elected to undergo this tattoo procedure.I understand that this procedure is a permanent change to my skin and body.Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results, and that independent results are dependent upon age, skin type/condition, and lifestyle.BROW CLIENTS ONLY: I understand that oily skin, skin with large pores, sun-damaged, very thick skin, very thin skin, skin with rosacea, and sensitive skin are not favorable skin types for microblading.I understand that in most cases this is a 2-step (and in some cases a 3-step) process, and I will possibly need to return after the initial procedure for further treatment(s) to obtain the expected results. I understand I must wait at least 4 weeks between procedures to ensure a proper healing period is given.I understand that with my paid initial procedure I receive one complimentary touch-up after 4-6 weeks. If I am not able to use the touch-up (due to moving, contraindication, etc.), there Is no partial refund, as it is is complimentary and thus has no cash value. Furthermore, if I cancel within 24 hours or no-show for my touch-up appointment, my complimentary touch-up will be forfeited. Any touch-up appointment scheduled thereafter will be charged at the standard touch-up rate of $100.I understand the importance of following all instructions given to me for post-treatment care in order to achieve optimal results. I will contact the artist with any questions regarding aftercare.IMPORTANT: I WILL protect my tattoo from UV/sun exposure while healing AND afterwards by covering it and/or wearing SPF 30+. I u D’etat a d that by failing to do this, I may compromise the color of my tattoo.I have given an accurate account of my medical history in the Medical and Skin History Form.acknowledge that this service is non-refundable.I acknowledge that the procedure involves inherent risks and possibilities of complications during and/or following the procedure such as: infection, allergic reaction, poor color retention, and hypo- or hyperpigmentation. I accept the permanence of this procedure and understand there is no guarantee that the color will ever fade out 100%, even several years from now. I also accept that there is no guarantee as to how long the color will remain in the skin.I fully understand that this is a tattoo process and therefore not an exact science but and art. I will be honest when asked by my artist if I approve of the shape, color, technique, and other aspects of the design.I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the cosmetic tattoo artist responsible for any of my conditions that were present but not disclosed at the time of treatment performed today.I agree not to exercise or expose the treatment area to excessive heat for 24-48hrs.I release Kannith Meas-Truong of all claims and injury, seen or unseen that may occur as a result of this procedure.I permit Kannith Meas-Truong to use any photos/videos recorded/taken of this service for marketing and portfolio purposes.
Name

First NameLast Name
Client Signature

Clear
Signed Date

MonthDayYear
Date
Should be Empty:

Cosmetic Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver