CONSENT FORM

This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetics application. If you have questions, please don't hesitate to ask.

Although permanent cosmetic tattooing is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing.

All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are stickily adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.

Initially the color will appear much more vibrant or darker compared to the end result. Usually within 57 days the color will fade 10-50%, soften and look more natural. The pigment is permanent but will fade somewhat over time and will likely need to be touched-up through the years.
Client Medical History Form

Please fill, sign and date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:*

MonthDayYear
Date
Age Verification: Please submit a picture of your ID or Passport, must be over 18*
Phone:
Email:
example@example.com
Emergency contact person full name:*
Emergency contact phone #*
Procedure desired:
Are you a client or model?
If you are interested in being a model for any of our services please register online. www.MarisGoddessEffects.com/models *Please note model services are completed by students under instructor's supervision.
How did you hear about our salon?
Do you presently have or previously had any of the following: *

BotoxDiabetesHIVLIP FILLERS/Restylane/JuvedermCold Sores/Fever Blisters ever?Blepharoplasty (Eyelid surgery)Hepatitis (A,B,C,D)Brow LiftFace LiftEasy BleedingAlcoholismEye Surgery/Injury/Corneal AbrasionAbnormal Heart ConditionContact Lenses nowPregnant now/Breastfeeding nowBrow or Lash tintingOily skinAccutane or Acne TreatmentKeloidVeganCancerUndergoing ChemotherapyTaking Blood Thinners, including Aspirin,Ibuprofen,alcohol,etc.Chemical PeelDifficulty numbing with dental workAllergic reaction to any medications such as Lidocaine,alcohol,etc.Allergies to metals, food,etc.Do you use any skin care products containing Retin-A, glycolic acid or alpha hydroxyl?Tan by booth or sunWaxingAny diseases or disorders not listed, list belowOther
*NOTE- some pain medications, Vitamin E, & B5 are blood thinners

If you have a serious medical condition you must come with a doctor's note stating the condition and the clearance to proceed with cosmetic tattooing. Mari's Goddess Effects will not be accountable for any unforeseen situations during your session.
Please list medications or vitamins you're presently taking:
I agree that all the above medical information is true and accurate to the best of my knowledge.
Possible risks, hazards or complications

Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. Lip procedures are more likely to involve some pain.

Infection: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See "After Care" sheet for instructions on care.

Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance.

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 or Bruising: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-5 days. Some people don't bruise or swell at all.

Eye Exposure: There is a small risk of eye injury when an eyeliner procedure is performed. To avoid corneal abrasion, Celluvisc, a thick eye drop is used to protect the eye prior to the procedure. Eye drops are used to cleanse and flush the eye after the procedure is complete. Please dont wear contacts for this service. Wear glasses. if you forget youll be asked to remove them. (Cases with solution are available for purchase in the salon @$5)

Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.

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.

Fever Blisters: (Lip Blush procedure) If you are prone to cold sores or fever blisters, (herpes simplex), there is a high probability that you will get them. It is advised that you call your doctor for a prescription antiviral to help prevent this from occurring.
Allergic Reaction: There is a small possibility of an allergic reaction.You may take a 5-7 day patch test to determine this.(To book test, please contact me.)Please initial to waive patch test or place a checkmark if you have taken this test in the last year.*
The alternative to these possibilities is to use cosmetics and not undergo the Permanent Cosmetics procedure.
STATEMENT OF CONSENT AND RECITALS: Please read and check all lines*

Fever blisters may occur in lip procedures in individuals who have the herpes simplex virus and it is my responsibility to obtain a prescription from my doctor for an anti-viral medication to help avoid a breakout.I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.Aftercare instructions have been explained to me and a written copy will be given to me to retain, which I will follow to the best of my ability. If I have questions I will call or email you. (Attached below)I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color.I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent make up. (Sunscreen is recommended once healed)I understand that successful lip color saturation can NOT be guaranteed due to hidden scar tissue.I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I'm scheduled for an MRI.I accept the responsibility for explain to you my desire for specific colors, shape, and position for any procedure done.I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch session within 60 days.I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.I have been quoted the cost of today's appointment which does not include touch up.I accept full responsibility for the decision to have this cosmetic tattoo work done.
I certify that I have read or have had read to me the contents of this form.I understand the risks and & alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered.I acknowledge that I have reviewed and approved the material given to me and I authorize Mari's Goddess Effects, as my permanent cosmetics technician to perform on my body the following procedures.This agreement will remain in effect for this procedure and all future procedures conducted by my technician.I have read the studios policy and agree to the associated fees regarding rescheduling and cancellation.Upon booking, client has paid a non refundable/non transferable fee. In no event shall the fee be refundable to the client. Fee is applied towards the client's service.I understand that there will be NO refunds after treatment of this elective procedure (s).I have read PMU booking section prior to booking, I am a candidate for this treatment.I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.
Signature

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Photography and Videography Release Consent Mari's Goddess Effects insurance company requires "Before" and "After" photos/videos be taken and kept on file. We would like your permission to use these photos/videos for advertising. For example, in portfolios,online and in print ads, etc. Your consent is necessary regarding this.t*

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Please save a copy of after care for your records. Screenshot or print.
Special requests, concerns or remarks for technician:
Should be Empty:

Client Medical History Form