Lip Blush Consent Form
Full Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Contact Number
Emergency Contact
How would you describe your skin?
Oily
Dry
Combination
Sensitive
The following conditions are recognized as contraindications for Lip Blush and must be disclosed and discussed with the specialist prior to treatment. Please check all that apply and give details below
Liver disease
Compromised skin near lip area
Pregnancy Breastfeeding
Chemotherapy / Radiation
Diabetes Type 1 or Type 2
Any medical condition that may cause contradiction.
Are you currently taking any medication?
Yes
No
Do you have any allergies?
Yes
No
Are you prone to cold sores?
Yes
No
Do you have Lip Fillers?
Yes
No
Do you get Laser Treatment?
Yes
No
Please check each box to show your understanding and agreement.
I am over the age of 18
I am not under the influence of drugs or alcohol
I am not pregnant or breastfeeding
I desire to receive the indicated Lip Blush procedure.
The general nature of cosmetic lip colour as well as the specific procedure to be performed has been explained to me.
The result of the procedure can be affected by the following: medication skin characteristics (dry oily sun damaged thick or thin skin type) personal pH balance of your skin alcohol intake and smoking post procedure after care.
I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have return for a repeated touch up procedure.
Upon completion of the procedure there might be swelling and redness of the skin which will subside within 1-4 days.
I have been advised that the true color will be seen 4-6 weeks after each procedure and that the pigment may vary according to skin tones, skin type age and skin condition.
I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.
I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.
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.
You may resume normal activities following the procedure however using cosmetics excessive perspiration and exposure to the sun should be limited until the skin has fully healed. Please see after care instructions for more details.
If an unforeseen condition arises in the course of the procedure I authorize my therapist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances.
I fully understand this is a tattoo process and therefore not an exact science but an art. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.
I am aware this procedure lasts up to 2-4 years depending on skin type. It will slowly fade. Yearly touch ups are recommended.
I accept the responsibility for determining the color shape and position of the PMU procedure as agreed during consultation.
We have your consent to take your photos for education purposes and post them online on my social media.
I have been informed that the highest standards of hygiene are met and that sterile disposable needles and pigment containers are used for each individual client procedure and visit.
I give Manmeeth Brar permission to perform my Lip Blush procedure. By my signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.
Name
Signature
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