CONSENT FORM

CONSENT FORM
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
DATE OF BIRTH

MonthDayYear
Date
E-mail
example@example.com
Nano BrowsCombination BrowsLip BlushFreckles
BEFORE COMBINATION BROWS/NANO BROWS/ LIP BLUSH/ FAUX FRECKLES:

4 WEEKS BEFORE:
- NO filler treatments, retinol, chemical peels, exfoliation treatments, or AHA's
2 WEEKS BEFORE:
- NO botox
- NO extented sun exposure
24-48 HOURS BEFORE:
- DO NOT consume alcohol, caffeine, blood thinners (advil ibprophen, etc)or pain killers, and avoid working out as this will thin your blood
I have been informed of the nature, risks and possible complications and consequences of cosmetic tattoo. I understand that cosmetic tattooing 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, or fading 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 form. I request the Combination brow and or Microblading procedure and accept the permanence of the procedure as well as the possible complications and consequences of said procedure. I understand that while this is sometimes referred as semi-permanent in nature, due to each individual's reaction to pigment, the length of the time pigment is present cannot be guaranteed. In some cases, pigment will be permanent.I understand that there may be certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Secondary infection in the area of the procedure may occur, however if aftercare is followed, is very rare.I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes may not be correctable.I authorize my artist to obtain pre/post procedural photos and give my artist permission to use such as photos for publication and/or for teaching purposes, as they choose.I have informed my artist of any existing health problems.Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have any questions, I will call/email my artist.I understand that sun, tanning beds, pools, some skin care products, and medications can affect my cosmetic tattoo.I understand that because pigments used in the permanent cosmetic procedures contain iron oxide, there may be a warming/tingling sensation in the area of my procedure during and MRI, therefore I must advise my physician that I do have a cosmetic tattoo, in the event an MRI is prescribed.I accept the responsibility to explain fully to you my desired for specific colors, shapes and positions for any procedure done today and that there is no refund policy.I have received pre- and post-procedure instructions and I will strictly abide by such instructions.I understand that if I have previous cosmetic tattooing by a previous artist that I must provide pictures before booking an appointment.I accept full responsibility for the decision to have cosmetic tattooing done.I certify that I have read the contents of this form. I understand the risks and alternatives involved in this procedure and I have had the opportunity to ask questions and all of my questions have been answered.I certify that I have read over cosmeticbyshey.com studio policies and and FAQ.
POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS:

PAIN: There can be pain even after topical anesthetic has been used.

INFECTION: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See the "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 unevenness.

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

NUMBING: 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.

ALLERGIC REACTION: There is a possibility of an allergic reaction to the pigments or other materials used. You may recive a 5-7 day patch test prior to your appointment to determine this.
AllergiesTumors/growths/cystsCancerCurrently pregnant/breastfeedingEasy bleedingBotoxTanning by booth or sunOily skinChemical peelFace liftForehead/Brow liftRetin-A, glycolic acid or alpha hydroxylAllergic reaction to any medicationsChemotherapy/RadiationAutoimmune disorderAlcoholismHepatitis (A,B,C,D)Taking blood thinnersAccutane or acne medication/treatmentBrow tintingAbnormal heart conditionDiabetesHistory of MRSA
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