PERMANENT COSMETICS CONSENT FORM
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Have you ever had a cosmetic tattoo or microblading procedure before?
Yes
No
What would you like to improve about your eyebrows or your lips? Consider shape, color, thickness...Please send me your bare eyebrows / lips without any makeup and filter
example@example.com
What service are you getting?
Ombre Powder Brows
Lip Blush
How did you hear about us?
Website
Instagram
Facebook
Referral
Other
Health History | Please check any of the following that applies to you
You have a history of herpes infection at proposed site
You are pregnant or nursing
You have epilepsy, hemophilia, anemia or bleeding disorders
You are on blood thinning medication
You smoke
You drink
You are on Accutane
You have taken Accutane withinthe last year
You have cardiac valve disease, a cardiac pacemaker or suffer from heart condition or abnormal heart condition
You are on steroids oranti-inflammatory medications
You suffer from Hepatitis or other blood borne pathogen exposure or any communicable diseases
You have had a Herpes Simplex Type 1 infection ( cold sores or fever blisters)
You have diabetes and use insulin or have any other conditions that cause delayed healing
You suffer from anymedical or skin conditions: such as keloids, psoriasis or any open wounds or lesions at procedural site
You bruise, swell or bleed easily
You use retin A, glycolid acid, vitamin C or other exfoliates
You suffer from hyperpigmentation skin condition
You have an autoimmune disorder or hypersensitivity
You had botox to raise your eyebrows
You have had work done on your lips (fillers, fat transfer, etc)
You have any allergies to latex or allergic reaction to topical numbing, pigment, aftercare A&D oitnment
You have had laser treatment.
You have had Cosmetic or Surgical Procedure, Radiotherapy or Chemotherapy during the past 6 months
You have had a chemical peel. When?
Other
Is there anything else I need to know about your health or healing that could complicate this procedure?
Please agree to the terms and conditions
I understand and accept such procedure is a process, often requiring a follow-up application of color to achieve desirable results and that 100%success is not guaranteed.
I acknowledge that obtaining permanent makeup is my choice alone, The application of permanent makeup will result a change in my appearance and that needles and pigments will go into my skin using only sterile disposable singleuse needles. No representations have been made to me as my ability to later restore the skin involved in permanent makeup to the original condition and canbe costly to remove.
I acknowledge infection is always possible as a result of permanent makeup and I agree to follow all suggested pre and post instructions concerning the care of the site while it is healing. Possibilities may include: redness, minor bleeding, swelling, tenderness, allergic reaction,and/or keloid formation.
I am aware that if I am to receive an MRJ after the procedure, I must tell my healthcare professional that I have iron oxide permanent cosmetics.
I understand that this procedure is permanent in nature but will fade overtime. The fading can alter the original color and that this determines that it is time for touchups. Touchups can be done every one to two years to up keep with color.
I agree to accompany my technician for blood testing in the event of accidental needlestick for their safety and disclose all test results to technician
I understand that I must comply with recommended pre and post care and following it is crucial forthe healing, preventing injection and results of treatment.
I understand that before and after pictures will be taken for purpose of documentation which mayor may not be used for educational or advertising purposes.
I am over the age of 18 and not under any influence of drug or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo at this time.
I understand that it is my responsibility to book my touchup accordingly to the time frame and each touch up fee is according to the time frame.
I understand there are NO guarantees and refunds will NOT be given.
I understand that this agreement will remain in effect for this procedure and all future procedures conducted by the technician.
I have read and understand these risks listed above and they have been explained to me. I have answered the questionnaire accurately and that it has been explained to me, I accept full responsibility for any complications that may arise during or following the cosmetic procedure(s) to be performed at my request.
I understand that the results of your procedure are determined in part by nature of the pathology ofskin type, but not limited to the following factors: Medicationsyou are currently taking; your skin characteristics; personal pH balance ofskin, tanning, fruit aids, AHA's, and retin A use; alcohol intake, smoking, sunexposure and improper skin care; following pre and post instructions.
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