Name
*
First Name
Last Name
I am over the age of 18, I am not under the influence of drugs or alcohol, I am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. PRINT NAME:
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DOB
*
Address
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ADDRESS
Street Address Line 2
CITY
STATE
ZIP
CELL/ MOBILE PHONE NUMBER
*
EMAIL:
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example@example.com
PROCEDURE(s):
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I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after an eyeliner procedure. I understand the actual color of pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and except the permanence of the procedure as well as the possible complications and consequences of the said procedure(s). Initial Below
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Allergic Reaction & Patch Testing Disclosure
There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. I consent to the patch test:
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INITIAL ABOVE TO AGREE TO THE PATCH TEST
I choose to waive the patch test. If waved, I release the technician from liability if I develop an allergic reaction to the pigment:
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INITIAL ABOVE TO WAIVE THE PATCH TEST
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable:
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INITIAL ABOVE
I have received pre-and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctors instructions before contemplating any permanent cosmetic procedure around my lips. I understand that the taking of before and after photographs of the said procedure(s) or a condition of such procedure(s). I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.
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INITIAL ABOVE
DATE
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/
Month
/
Day
Year
Date
Signature
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PROCEDURES DESIRED
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Eyeliner
Eyebrows
Lipline
Full Lip Color
Nipples
Beauty Mark
Skin Repigmentation
Other
If you selected "other" please explain:
HAVE YOU EVER HAD A COLD SORE?
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YES
NO
I have read the above information regarding ZOVIRAX and understand its use is mandatory if I desire lipline or full lip color procedures:
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Who referred you:
Are you currently under the care of a physician?
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YES
NO
If so, why?
Physician's name:
Do you take antibiotics when going to the dentist?
Yes
No
If Yes, Why?
Do you suffer from:
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Heart Problems
Hemophilia
Diabetes
Skin Problems
Scarring (Keloids)
Eye Problems
Epilepsy
Allergies
Moles or freckles at site of tattoo
Hepatitis
Other
If other, please explain:
Are you presently taking any medication which thins the blood?
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Yes
No
Are you taking other medications?
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Yes
No
If yes, explain:
Are you pregnant or nursing?
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Yes
No
Do you wear contact lenses?
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Yes
No
Date:
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/
Month
/
Day
Year
Date
I have thoroughly read and disclosed all required information within this consent and intake form. I understand that if I fail to cancel my appointment within 24 hours, there will be a charge of $150
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