Consent For Permanent Makeup Procedure

Consent For Permanent Makeup Procedure
California Safe Body Art Act, Section 119303(a)

All information gathered from the client/patient that is personal medical information and is subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or similar state laws shall be maintained or disposed of in compliance with those provisions.
Name
DOB
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip
Phone Number
Join our Mailing List
Stay up to date for deals, events and with our newsletter!
Who referred you?
What are your pronouns?
Photo ID

Please upload a copy of your photo ID
Cancelof
Symptoms of COVID-19 may appear 2-14 days after exposure to the virus. People with these symptoms are prohibited from entering the premises.

In order to ensure the health and safety of our staff and clients, please answer the following questions truthfully and to the best of your knowledge. Your responses will be kept confidential.
Please indicate if you are experiencing any of the following symptoms

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea
Proof of Vaccination

Cancelof
Are you currently under the care of a physician due to the conditions listed below?

YesNo
Do you suffer from or take medications related to any of the following:

DiabetesSkin ProblemsHemophiliaDo you suffer from any of the following?Scarring (Keloids)Eye ProblemsMoles or Freckles at Site of TattooHepatitisHeart ProblemsCancerEpilepsyHIVCold SoreHerpes infection at the proposed procedure site?Cardiac Valve Disease
Are you presently taking any medication which thins the blood?
Are you taking other medication? If yes, explain
Are you pregnant or nursing?

Yes
Do you wear contact lenses?

Yes
Do you have any known allergic reactions to latex or antibiotics?

Yes
STATEMENT OF CONSENT AND RECITALS: PLEASE READ AND INITIAL ALL LINES
(Initials) I understand there are risk factors for blood borne pathogen exposure.
(Initials) I will follow my aftercare instructions to the best of my ability. If I have questions, I will call or email my Technician. I understand that failure to follow aftercare instructions may result in the necessity for additional touch ups.
(Initials) I understand that a certain amount of discomfort is associated with this procedure and swelling, redness, and bruising may occur.
(Initials) I understand that RetinA, Renova, Alpha Hydroxy and Glycolic Acids must not be used treated areas. They will alter the color and cause premature exfoliation of the pigment.
(Initials) I understand that tanning beds, pools, and some skin care products and medications can alter my permanent makeup.
(Initials) I understand that if I am concerned about allergic or other reactions to permanent makeup such as keloid I will have a patch test performed prior to having the permanent makeup procedure.
(Initials) I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.
(Initials) I accept the responsibility to explain my desire for specific colors, shape, and position any procedure done today to my Technician.
(Initials) I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond control of both the client and the Technician, and I will need to maintain the color with future applications and a touch up session within 60 days.
(Initials) I acknowledge that the proposed procedure(s) involve inherent risks and have the possibility of complications during and/or following the procedures such as, but not limited to: infection, misplaced pigment, poor color retention, and hyper pigmentation.
(Initials) I have been advised that a touch up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Touch ups must completed within 60 days of the initial procedure.
(Initials) All information gathered from the client that is personal medical information and that is to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or similar laws shall be maintained or disposed of in compliance with those provisions.
(Initials) I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs 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.
(Initials) I understand I will have permanent makeup applied using appropriate instruments and sterilization techniques. I understand that the permanent makeup site usually takes approximately 2 weeks or longer to heal. I agree to release and forever discharge and hold harmless the Technician, employees, contractors, and the management of the permanent makeup studio from any and all of negligence, damages, or legal actions arising from or connected in any way with my tattoo procedure and conduct used in my tattoo and assume all responsibility for the decision(s) made to this permanent procedure.
(Initials) I am aware that tattoo inks, dyes, and pigments have not been approved by the federal and Drug Administration and that the health consequences of using these products are unknown.
(Initials) I am not pregnant or nursing. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorders. I do not have cardiac valve disease or suffer any heart conditions or take medications that thins my blood.
(Initials) If I suffer from hepatitis, or other risk factors for blood borne pathogen exposure, or any communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedures necessary to promote the satisfactory healing of my tattoo.
(Initials) I do not suffer from any medical or skin condition(s) such as, but not limited to: cold sores/herpes, keloid or hypertrophic scarring, psoriasis at the site of the permanent makeup, or any wounds or lesions at the site of the tattoo. In the event that I do experience cold sores in the area being tattooed I will take antiviral medication 5 days prior to and 5 days post procedure.
(Initials) I have advised the Technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have a reaction to the permanent makeup process and further acknowledge that such reaction is possible.
(Initials) I certify that I have read or have had read to me the contents of this form. I understand risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, all of my questions have been answered. I acknowledge that I have reviewed and approved the design given to me, and I authorize my permanent makeup Technician to perform on my body the permanent cosmetic procedure desired today. I hold Hallie Kibert, Adorn Permanent Cosmetics, Studio Noir, and any affiliates harmless for any and all physical risk or damage.
(Initials) I am over the age of 18, am not under the influence of drugs or alcohol, and desire to have permanent make up.
(Initials) I have been informed of the nature, risks, possible complications, and consequences of permanent skin pigmentation. 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, allergic reaction, scarring, inconsistent color, and spreading, fanning, or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent makeup procedure and accept the permanence of the procedure as well as the possible complications, side effects, and consequences of the procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each individual's reactions to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent.
(Initials) I understand that if I have any skin treatments, laser hair removal, plastic surgery, or skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.
(Initials) I have read my pre care instructions and will strictly adhere post procedure instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood-altering prescription, I will advise my Technician. I understand that the taking of before and after photographs of the procedure is a condition of such a procedure and these images could be used unless you specify otherwise. I certify I have read and initiated the above paragraphs and the risks have been thoroughly explained to me. I understand what I have consented to and the procedure(s) I am consenting to have performed upon my skin. I accept full responsibility for the decision to have this permanent cosmetic procedure performed.
(Initials) I understand that if I fail to cancel my appointment within 48 hours, there will be a $100 cancellation fee.
Signature

Clear
Date

MonthDayYear
Date
For Technician Use

Before and after photo
Cancelof
For Technician Use
Needle and Ink Records, Client Notes
Should be Empty: