This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetic procedure. If you have questions, please do not hesitate to ask. Although the elective procedures are effective in most cases, no guarantees can be made that a specific client will benefit from the procedure.
This is a process of inserting pigment into the dermal layer of the skin; a form of tattooing. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are strictly followed.
Our goal is to deliver the desired aesthetic goals for each client, however, a perfect result is an unrealistic expectation. It is common to expect touch-ups after healing is completed. Initially, the color will appear much more vibrant or darker compared to the end result. The pigment used will fade over time and will likely need to be touched up within 6 months to 3 years.
PAIN: There could be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. Please communicate with your technician how you’re doing throughout procedure.
INFECTIONS: Infection is very unusual. The areas treated must be kept clean and only touched with freshly cleaned hands. If you follow the specific after care instructions provided to you infection is highly unlikely
UNEVEN PIGMENT: This can be a result of not following aftercare instructions, poor healing, infection, bleeding, or other causes. Your follow up appointment will likely help correct any uneven appearances.
ASYMMETRY: Every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness.
EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. It typically disappears within 1-5 days. Some people do not bruise or swell at all.
ANESTHESIA: Typical anesthetics are used for numbing the area to be tattooed. Lidocaine, Tetracaine and Epinephrine in a cream and gel form are used. If you are allergic to any of these please inform your artist immediately.
MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.
ALLERGIC REACTION: Less than a 0.25% of the population has an allergic reaction but there is a small possibility. Doing a spot test is recommended if you have had reactions in the past.
COVID-19 Policies (in affect until further notice)
I authorize Jordan Schirmer, professional permanent makeup artist, to perform my elective permanent makeup procedures. The risks of the procedure have been disclosed to me. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made, and I acknowledge that I have received no particular representations or guarantees, and I am consenting to the procedure at my own risk. I have revealed or disclosed on the Medical Profile form all conditions and circumstances regarding my health and health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could occur or be discovered during or after the procedure, which could affect my ability to tolerate the procedure.
I understand the success of my permanent cosmetics process requires my careful maintenance. I understand that I must strictly adhere to all aftercare instructions. I understand that failure to follow after-care instructions may result in infection, pigment loss, or discoloration. I agree to and understand all of the above information and consent that all of the information is correct to the best of my knowledge.
I, as herein signed, release, give up, acquit and discharge my permanent cosmetics professional at Lush Beauty Loft from any claims or damages of any nature. I agree to pay any costs of legal services necessary to further effect or confirm said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this waiver and release form, and said damages are specifically waived following the signing of this waiver and release form. I further agree to hold my permanent cosmetics professional nameless and harmless from any and all damages.
I release my permanent cosmetics professional from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure. I understand that I am responsible for any medical treatment I may need as a result of getting this procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the procedure, which is to be performed at my request.
Please read the following statement and sign and date on the line to indicate that you have read, understand and accept the following statement:
I, the client herein signed, certify that I have read and fully understand the above waiver and release form. I certify that I have read all applicable literature given to me. I have completed the above forms to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this waiver and release form for myself. I, the undersigned client, acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time. I, the client herein signed, for the purposes of documentation, hereby consent to “before and after” photographs, which may or may not be used for the purposes of advertising.