Semi-Permanent Cosmetic Consent Form

Name

First NameLast Name

Date of Birth (MUST BE 18 OR OLDER NO EXCEPTIONS)

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Upload a photo of your Drivers license or ID

(Must be 18 or older, a photo of your passport is also acceptable.)

Procedure

Clinical outcome of procedure(s):

The results of your procedure are deteremined in part by natrure of the pathology of skin type but not limited to the following factors:

Medications you are currently taking; your skin characteristics; personal pH balance of the skin, tanning, fruitcaids, AHA's, and retin A use; alcohol intake, smoking, sunexposure and improper skin care; followig pre and post instructions.

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. Initial*
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 single use needles. No representations have been made to me as my ability to later restore the skin involved in permanent makeup to the original condition can be costly to remove. Initial*
I acknowledge infection is always possible as a result of permanent makeup and I agree to follow all suggested 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. Initial*
I understand that position of my procedures can be affected if I elect to have cosmetic surgery and/or cosmetic botox and fillers. Initial*
I am aware that if I am to receive an MRI after the procedure, I must tell my healthcare professional that I have iron oxide permanent cosmetics. Initial*
I understand that this procedure is permanent in nature, but will fade over time. the fading can alter the original color and that this ermines that it is time for touchups. Touchups can be done every one to two years to keep up with color. Initial*
I agree to accompany my technical for blood testing in the event of accidental needle stick for their safety and disclose all test results to technician. Signature*
I understand that I must comply with recommended pre and post care and following it is crucial for the healing, preventing injection and results of treatment. Initial*
I understand that before and after pictures will be taken for the purpose of documentation which may or may not be used for educational, advertising, and promotional purposes on social media. Initial*
I am over the age of 18 and not under any influence of drug or alcohol. Initial*
I understand that it is my responsibility to book my touchup accordingly to the timeframe and each touchup fee is according to the time frame. Initial*
I understand there are NO guarantees and refunds will NOT be given. Initial*

I have read and understand the risks litsted above and they have been explained to me. I have answered the quiestionnaire accurately, i accept full responsibility for any complicaitons that may arise during the following cosmetic procedure(s) to be performed at my request.

Signature of client

Todays date

Date

Medical History

Rows	Yes	No
Do you have a history of herpes infection at proposed site? (ie. cold sores)
Are you pregnant or nursing?
Do you have epilepsy, hemophilia, anemia or any bleeding disorders?
Are you on any blood thinning medication?
Do you smoke?
Have you drank Caffeine in the last 48 hours?
Have you drank Alcohol in the last 48 hours?
Are you on Accutane? Or have you taken Accutane within the last year?
Do you have cardiac valve disease?
Do you suffer from any heart condition?
Are you on steroids or anti-inflammatory medications?
Do you suffer from Hepatitis or other blood borne pathogen exposure or any communicable diseases?
Do you have diabetes and use insulin?
Do you suffer from any medical or skin conditions such as: Keloids, psoriasis or any open wounds or lesions at procedural site?
Do you bruise, swell or bleed easily?
Do you use Retin A, glycolic acid, vitamin c or other exfoliates?
Do you have an autoimmune disorder?
Exiting tattoos?
Have you had Botox to raise your eyebrows?
Do you have any allergies to latex?
Have you had a chemical peel in the last 6 months?
Have you had laser treatments in the last 6 months?

Is there anything else I need to know about your health/ skin?

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$50 deposit

All deposits and fees are non refundable.

$50.00

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Semi-Permanent Cosmetic Consent Form

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