Paramedical Service Consent Form

THE ARTISTRY BEAUTY STUDIO

22672 Lambert Street #604 Lake Forest, CA 92630 PH: 949-424-2104 THEARTISTRYBEAUTYSTUDIO.COM
Informed Consent, Release and Medical History Agreement

for Paramedical Treatments. Please complete all sections that apply
The information you provide on this form is strictly confidential and will be used to ensure your safety and the success of your procedure. Please take a few moments to read through each section and answer honestly. Your comfort, care, and well-being are important to us, and we truly appreciate your trust.
Procedure Description
This procedure involves the use of cosmetic and paramedical tattooing techniques to implant pigments/inks into the upper layers of the skin. It is commonly used to soften the appearance of scars or recreate the look of natural areolas and nipples following surgery. All procedures are performed using traditional tattoo techniques and using single-use, disposable needle cartridges and to ensure the highest standards of safety and hygiene.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Artist*
Date of your service IF already scheduled

MonthDayYear
Date
How did you hear about us?
If referred you please provide their name and phone or email, so we can thank them.
Desired Treatment*

Camouflage Tattoo (Scars / Stretch Marks)Inkless Treatment3D Areola & Nipple TattooAreola Scar(s) CamouflageOther
Treatment Area*

BreastButtocksAbdomenBackArmsHipsLegsAreolasOther
Are you currently nursing or pregnant?*

YesNo
Do you have any allergies to adhesives?*

YesNo
Are you over the age of 18 and in sound mind, body, and health?

YesNo
Are you currently undergoing radiation or chemo therapy?

YesNo
Do you currently have any active viral or bacterial infections? (If so, please reschedule this appointment)

YesNo
Are you now or have you ever been on Accutane? (You must be off accutane for at least 6 mos in order for us to service you)

YesNo
Are you allergic to antibiotics?

YesNo
Are you allergic to Latex?

YesNo
Are you allergic to Lidocaine, Epinephrine or any other numbing agents?

YesNo
Are you allergic or sensitive to any metals, such as those found in jewelry or medical equipment?

YesNo
Please list any known allergies, as well as all medications you are currently taking, including both prescription and over-the-counter medications:
Have you had any chemical peels or injectables (botox, Restylane, etc.) or fillers on the or near the area of treatment within the last 2 weeks?

YesNo
Is the skin surrounding the scar(s) currently tanned?

YesNo
Have you had any complications with previous tattoos or permanent makeup in the past?

YesNo
Do you tend to develop Keloids? (raised/bubbled scars)

Yes, I am proneNoNot prone but have had an isolated occurrenceUnsure
Any complications with past surgeries? Infections, etc?

YesNo
Please check all relevant conditions:

Allergies - Hand creams or body lotionsAllergies to MakeupAnemia - Can affect Pigment RetentionAsthmaCancer (any type)Seizures or EpilepsyHyper-pigmentation (scars heal dark)Hypo-pigmentation (scars heal white)Thyroid - Hyper/ HypoTrichotillomaniaVitiligoFaintingEczema/ PsoriasisBleeding Disorders (e.g. hemophilia, Von Willebrand disease)I bruise easilyI have a history of excessive bleeding during proceduresOther
Are you currently taking any prescribed or over-the-counter medications, supplements, or antibiotics that may interfere with healing or increase bleeding risk? (Examples: blood thinners, aspirin, fish oil, vitamin E, or antibiotics prescribed before dental or surgical procedures)

YesNo
Are you Diabetic?

YesNo
Do you have any heart conditions, including valve disease or valve replacement?

YesNo
Have you ever been diagnosed with Tuberculosis (TB)?

YesNo
Have you ever been diagnosed with a bloodborne illness?Examples include HIV, Hepatitis B, or Hepatitis C?

YesNo
Do you have any autoimmune disorders or diseases? (e.g., lupus, rheumatoid arthritis, Hashimoto’s)

YesNo
Do you have any autoimmune disorders or diseases? (e.g., lupus, rheumatoid arthritis, Hashimoto’s)

YesNo
Please list any medical conditions you have that have not already been mentioned and that may impact these services or affect your healing process:
Please provide any explanations or information that you feel is important for us to know in relation with your health and this treatment:
List all surgeries elective or non-elective that you’ve had in the past 2 years (Type of surgery, month/year)
Mastectomy/ Breast Cancer Clients Only
Mastectomy:

BilateralUnilateral
Month and Year of your Mastectomy:
Month/Year
Month and Year of your last breast reconstruction:
Month/Year
If you had chemo or radiation please note month and year of last treatment:
Month/Year
Reconstruction Type (select all that apply)

Breast ImplantsFat GraftingFlapNipple SparringN/A
Do you plan to undergo any additional procedures or revisions related to breast reconstruction including fat grafting, within the next year?
Have you experienced any complications during or after any of your surgeries? If yes, please explain:
Please note:
Any clients/ patients which surgery was less than 3 years ago will need to provide a release letter from their Doctor. It is very easy to obtain just call your surgeon and let them know you need a clearance letter to get your areola restorative tattoo.
Possible Risks, Hazards or Complications
INFORMED CONSENT

You have the right to be informed so that you make the decision whether or not to undergo the procedure(s) after knowing the risks and hazards involved. The disclosures is not meant to frighten you, it is simply in an effort to make you better informed so you may give or withhold your consent to the procedure.

What to Expect After the Procedure
After the procedure, the treated area may appear slightly red, swollen, or feel tender for the first few days. It is normal for the color to appear darker or more intense initially — this will soften as the area heals. Mild peeling or flaking may occur around days 5 to 14. Full healing typically takes 5 to 8 weeks, and the final color may fade by approximately 30% as the skin regenerates. Clients typically require more than two sessions to achieve their desired results, especially when working on scar tissue.
I understand that a certain level of discomfort is associated with this procedure and that swelling, redness and soreness will occur. *
Please initial
Infection: Although rare (less than a 0.25% of the population) there is a risk of infection. The areas treated should be kept clean and only touched with clean washed hands. See "After Care" instructions given and available online *
Please initial
Uneven Pigmentation: Can result from poor healing, infection, bleeding or many other causes including type of the skin, your follow up appointment will likely correct any uneven appearances. *
Please initial
Excessive Swelling or Bruising: During and after the procedure, temporary swelling, redness, scabbing and /or itching may occur. If excessive swelling, discomfort, or fever occurs, call our studio to let us know and see a doctor immediately to ensure it is not an infection or allergic reaction. *
Please initial
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're allergic to any of these or any other anesthetics please let your artist know immediately*
Please initial
MRI: Pigments used in permanent cosmetic procedures may contain iron oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI technician of any tattoos including permanent makeup.*
Please initial
Allergic Reaction: Although rare, there is a possibility of an allergic reaction to the most advanced and top quality pigments used or other materials used in todays appointment. The client is informed about this and he/she assumes liability. You may take a 5-7 day patch test at least 14 days prior to your appointment to determine this.*

WaiveTake Patch Test (please contact me ASAP)
Please note that for Scar Camouflage and Areola Tattoo procedures, there is a high likelihood of using white inks containing titanium oxide. It is crucial NOT to attempt laser removal on or near the camouflaged areas, as it can adversely impact the desired results. Acknowledge by initialing below*
Please Initial
Contractual Obligations

Please initial each line
I have accurately completed this form and provided my Medical History*
Please Initial
I have been candid in revealing any condition that could prohibit or alter my treatment/procedure such as, but not limited to, pregnancy, recent surgeries, sun exposure/tanning, cold sores, tendency of scarring, breastfeeding and use of Accutane in the past 12 months*
Please Initial
I have not taken any antibiotics within 30 days of my scheduled appointment*
Please Initial
I acknowledge that paramedical services, including camouflage tattoo, areola tattoo or inkless rejuvenation treatments provided by Priscilla and Elaine, aim to improve/enhance the overall appearance of scars and stretchmarks. It is important to understand that these services are designed to for "improvement", and they will not make the imperfections completely disappear. I further acknowledge that I was not promised "perfect" results.*
Please Initial
I understand that there is a possibility of undesirable results and know that each person's outcome is different, and there are no guarantees to my results. I agree that The Artistry LLC and Evolve Med Ink nor the technicians made any guarantees*
Please Initial
I understand that disposable needles are used for this procedure*
Please Initial
I understand that the color of my treatment area will intensify and darken for the first 3 weeks and intensity will slowly subside over the next few weeks and full healing can take up to 6 months. I will trust the process and refer to the What to Expect information provided to me.*
Please Initial
For Camouflage & Areola Tattoo, I understand that the implanted pigment color can alter or fade dependent on skin, skincare products and lifestyle and that one or more additional treatments will be required.*
Please Initial
I understand that all treatments may require 2-7 sessions, depending on the service, how well my skin responds and my individual results and goals. And additional sessions are available at an additional cost as stated in proposal/quote*
Please Initial
I acknowledge that this treatment as with all treatments and procedures inherent risks and that there is a possibility of one or more complications during and/or following the procedures such as infection, misplaced pigment, poor color retention and hyper-pigmentation (darkening of scars) If at any time during the healing process I experience Increased pain, develop a fever or suspect an infection I will Immediately call my artist to inform and seek medical advice*
Please Initial
I understand that camouflage tattoo procedures with flesh tone inks tend to use inks that contain the color white and therefore it is never recommended to NEVER attempt laser tattoo removal on scars and stretch marks that have been camouflaged. *
Please Initial
Aftercare instructions have been provided to me up front, and are also available on our website theartistrybeautystudio.com I understand that inadequate care in the healing phase of the skin can lead to poor results or infection and The Artistry LLC, Evolve Med Ink and the technicians cannot be liable for it. If I have questions I will call my artist or the studio*
Please Initial
I understand that for better and longer lasting results and prevent color from fading it is recommended I protect my tattoo with SPF 30+ when out in the sun. I further understand that I am not to expose treated areas to the sun for the first 40 days.*
I attest that I request the Scar/ Stretch mark treatment and accept the permanence of the procedure as well as the possible complications and consequences of the procedure.*
Please Initial
Privacy Notice
As required by California law, this form and any personal information collected are kept strictly confidential and used solely to evaluate your eligibility and safety for body art procedures, including paramedical tattooing. Your records will not be shared with third parties without your written consent, unless required by law. All information is securely stored and used only to provide you with safe, informed, and appropriate service and care.

Photo/Video Media Release
Before-and-after photos play a powerful role in helping others understand what’s possible. These images don’t just show results — they give hope. Many individuals are navigating their own journeys with scars, surgeries, or healing, and seeing real examples can help them feel encouraged and less alone. Because of this, we may take photographs and/or videos before, during, and after your procedure for documentation purposes. With your permission, these images may also be used on The Artistry Beauty Studio or Evolve Med Ink websites, social media, printed materials or for educational purposes. Most photos are close-ups of the treated area and do not show your face or personally identify you — unless you allow it.
Please SELECT ONE ONLY:*

I authorize The Artistry LLC and Evolve Med Ink to use of my photos/videos WITHOUT RESTRICTION , including images where my face may be visible.I authorize The Artistry LLC and Evolve Med Ink to use of my photos/videos "with the following restrictions": ONLY CLOSE-UP IMAGES of treated area may be used. WILL NOT INCLUDE MY FACE or anything that could personally identify me.I do not authorize The Artistry LLC or Evolve Med Ink to use of my photos/videos for marketing or educational purposes.
Note: Regardless of my selection above, photographs may still be taken and stored as part of my confidential client record.*
Please Initial
Consent and Agreement
I acknowledge that I am at least 18 years of age and I certify that I have read or someone read the contents of this form to me. I understand the risks and alternatives involved in this procedure as stated. I have had the opportunity to ask questions and all of my questions have been answered.

I realize my body is unique and the artist cannot predict how my skin may react as a result of the procedure. I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as the ability to later change or remove the result.

I understand that future laser treatments or other skin altering services or products may alter or degrade by permanent makeup. I understand that such changes are not the fault of the practitioner. I further understand that such changes may not be correctable through future permanent makeup or removal.

I acknowledge that obtaining paramedical tattooing services is by my choice alone, and I consent to the application of the procedure and its risks, and to any conduct or actions of the practitioner reasonably necessary to perform the procedure. Tattoos should be considered permanent; that it can only be removed with a surgical or invasive procedure; and that any effective removal may leave permanent scarring and disfigurement. The Artistry LLC and Evolve Med Ink make no attempt or claim to practice medicine.

I understand that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. I further understand that the cosmetic tattooing service is permanent, and no promises have been made in the ability to remove or alter the results.

I acknowledge that I have reviewed and approved the materials given to me and I authorize the Artist of The Artistry, L.L.C and Evolve Med Ink to perform Paramedical treatment(s) on me. I hereby release and forever discharge The Artistry, L.L.C, Evolve Med Ink and its technicians and affiliates from all demands, actions or cause of action and any liability arising from the performance including the risks of Micro-pigmentation procedure done today and for all future appointments. It is further acknowledged, that IF I authorized above and grant permission to use before and after photographs, they will be used for Advertising for The Artistry LLC and Evolve Med Ink (i.e. portfolios, brochures, online, social media or print advertisements and teaching materials).

DIGITAL FORM SUBMISSION IS ACCEPTANCE OF TERMS OF SERVICE
I acknowledge that NO refunds after any services will be given.*
Please Initial
By submitting this form electronically, I acknowledge that my digital signature is the legal equivalent of my handwritten signature and represents my agreement to the terms outlined above.
Signature*

Clear
Print Name*

First NameLast Name
Date*

MonthDayYear
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THE ARTISTRY BEAUTY STUDIO

Informed Consent, Release and Medical History Agreement

Mastectomy/ Breast Cancer Clients Only

Possible Risks, Hazards or Complications

Contractual Obligations

Consent and Agreement