Lip Blushing New Treatment Client Consent Form
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  • Lip Blushing New Treatment Client Consent Form

  • Client Information

  • Date of birth*
     - -
  • Format: (000) 000-0000.

  • Pre-Procedure Questionnaire

  • Are you under the influence of drugs or alcohol?
  • Are you pregnant or nursing?
  • Do you have a communicable disease?
  • Do you have any skin conditions?

  • Acknowledgment and Waiver

  • Have you ever had a cold sore? If yes, you must contact your physician for a prescription of ZOVIRAX capsules, an antibiotic which prevents cold sores before having a lip blush procedure done.*
  • Signed Date*
     - -
  • Are you currently under the care of a physician?*
  • Do you take antibiotics when going to the dentist?
  • Do you suffer from:
  • Are you presently taking any medication that thins the blood?
  • Are you taking any other medications?
  • Are you pregnant or nursing?
  • Date
     - -

  • Client information sheet

  • Do you have(check all that apply)
  • Do you use(check all that apply)
  • Format: (000) 000-0000.
  • DOB:
     - -

  • I,   am over the age of 18, I am not under the
    influence of drugs or alcohol and desire to receive the indicated permanent cosmetic
    procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.        

  • PROCEDURE(s):      
    NO. OF VISITS REQUIRED:      
    COST OF PROCEDURE(s):      

  • I hereby authorize    to perform the permanent makeup procedure
    we have discussed, on the following area:      

  • I have been informed of the nature, risks, and 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 skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s).      

  • I understand that if I have any skin treatments, including but not limited to lip fillers, botox, plastic surgery, peelings, laser hair removal, plastic surgery or other 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. I have received pre and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize
    my chances for a successful procedure.      

  • I have been informed about recommendations and instructions to be followed after the procedure. I acknowledge that according to my mental and physical conditions, I am not considered to be an at-risk customer, for not suffering from any of the conditions described by the practitioner at the time of consultation, therefore accepting that such complications are not at fault of the practitioner and holding both the company and technician harmless from same.      

  • I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up.      

  • I acknowledge that it is not always possible to determine in advance whether I might have an allergic reaction and agree to accept the risk for not taking an allergy test with a Licensed Allergist Doctor prior to the procedure.      

  • I take full responsibility for following the aftercare recommendations and accept that failure to follow after care directions are not at fault of both the company nor the practitioner. I have been informed about the nature and method of the proposed permanent makeup procedure and I consent that the suggested design and drawing project, such as thickness, format and chosen pigment color are satisfactory, fulfilling my expectations.      

  • I have received pre- and post procedure instructions and I will strictly adhere to such 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. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.      

  • I am aware that if an infection occurs after I have received Permanent Cosmetics to see with my primary physician or an emergency room immediately.      

  • I understand that the taking off before and after photographs of the said procedure(s) are a condition of such procedure(s). I hereby grant the full right to take, publish and reproduce photographs/videos of my face, me, my eyebrows, both before and after procedure, for any advertising education or other purposes whatsoever, including the right to retouch these photographs as deemed necessary.      

  • I certify that the information in the above questionnaire is accurate and my questions have been answered. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I further certify that I have completed the Client profile and Health History Form accurately and completely to the best of my knowledge, and that I understand the potential complications and risks described herein. I accept full responsibility for the decision to have this cosmetic tattoo work done.      

  • Date
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  • Date
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  • Should be Empty: