Permanent Makeup Consent Form

Name

First NameLast Name

E-mail Address

Mobile

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Occupation

Date of Birth

Please read these statements carefully. •Permanent cosmetics are a form of tattooing. •Retouch procedures may be required. •A healing period of 6 to 8 weeks is required before any touch-up procedure can be performed. •On rare occasions, the pigment may migrate under the skin. •Application of permanent cosmetics can be uncomfortable. •The pigments will eventually fade. •Immediately after the procedure, the pigment can be 30 to 50% darker than the desired result. •There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare. •A negative allergy test result will not guarantee that you will not have an allergic reaction. •Infections can occur if aftercare is not followed. •Allergic reactions to anesthetics may occur. •There may be swelling and/or redness following the procedure. •You may experience minor bleeding. •If you had an MRI scan within the last 3 months of your permanent cosmetics procedure, we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.

Close up of right brow / lips / area being treated

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Close up of left brow / lips / area being treated

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Close up front view of both brows/lips/area being treated

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Full facial to show the shape of your face / area being treated

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Treatment Required.

Please describe your ultimate goal from this treatment.

Please list all the medication taken within the last 6 months

Have you taken any of the following in the last 48 hours?

Rows	Yes	No
Aspirin
Ibuprofen
Coumandin
Alcohol

Have you ever had an allergic reaction to any of the following?

Rows	Yes	No
Anesthetics
Adrenaline
Latex Rubber
Vaseline
Crayons
Metals
Drugs
Paints
Lanolin
Foods
Medication
Glycerine
Lidocaine
Another allergy not listed

If 'yes' or 'another allergy' please provide additional information below

Have you received chemotherapy or radiation treatment in the last year?

Please select yes to the following that apply to you:

Rows	Yes	No
Abnormal Heart Condition
Cold Sores (herpes simplex)
Mitral Valve Prolapse
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumors, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Palpitations
Hepatitis
Cataracts
Blurred Vision
Dry Eyes
Eye Infection present
Alopecia
Recent Hair Loss
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Gore-Tex Implants/Silicone Injections
Fat Transfer Injections
Botox Injections
Collagen Injections
Hypertrophic Scars
Keloid Scars
Scar Easily
Healing Problems
Bruise or Bleed Easily
Sensitivity to Cosmetics
Use of Sun bed
Acutance within 6 months
Cortisone within 6 months
Chemical or laser peel within 6 months
Retin A within 6 months
AHA preparations within last 2 weeks

1. I hereby authorize Liz (Lizthethics) to perform the microblading/powder ombre brows, lip blushing, nano brows, combo brows, scar camouflage, Areola pigmentation procedure, whichever applies, on me. 2. If any unforeseen condition arises in the course of this procedure(s), calling in their judgement in addition to, or different from those now contemplated, I further request and authorize the Permanent Makeup (PMU) artist to do whatever they deem advisable and necessary in any given circumstances. 3. I accept responsibility for determining the color, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. 4. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I confirm I have completed a patch test for this procedure, within 6 months of the treatment date. 5. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in 1-3 years. 6. I have been informed that the highest standards of hygiene are met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit. 7. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results and that 100% success cannot be guaranteed. I understand this is why I need to return for a touch up procedure. 8. I understand that a touch up procedure will need to be performed within 2-3 months after the initial procedure and after the 3-month period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties. 9. The result of the procedure is determined by the following: - Medication - Skin Characteristics - (dry, oily, sun-damaged and thickness) - Natural skin undertones - (blending with chosen pigment) - Personal pH balance of skin, which changes from visit to visit - Alcohol intake and smoking - Post procedure care treatment. 10. Upon completion of the procedure there may be swelling and redness of the skin, which will subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately following the procedure, however, using cosmetics, excessive sweating and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. You can however, be assured the procedure, even after only one treatment, looks acceptable and you should feel comfortable appearing in public without additional makeup on the affected area. 11. I have been advised that the true color will be seen 1 month after each procedure, and that the pigment may vary in color according to skin tones, skin type, age and skin conditions. I understand that some skins accept pigment more readily than others and no guarantee to an exact effect or color can be given. 12. I am informed that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment. 13. 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 the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol, pregnant or breastfeeding. 14. I agree to follow all pre and post-procedure instructions as provided and explained to me by the Permanent Makeup (PMU) artist. 15. Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by Liz (Lizthetics) 16. For the purpose of documentation, advertising in portfolios, social media such as Facebook, Instagram, online and in print ads, etc., I also consent to the taking of “before” and “after” photographs/or videos of the PMU procedure(s)

Allergic Reaction– Allergic reaction can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptoms associated with allergy. Numbness - We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is totally numb while others say they experience some discomfort. Procedure – For all procedures a cream or gel topical anaesthetic is used. These products are perfectly safe, and can be purchased over the counter from any chemist. The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between 1-4 days. You should always follow your post procedure instructions.

IF YOU EXPERIENCE AN INFECTION OR ADVERSE REACTION AFTER THIS PROCEDURE, CONTACT YOUR DOCTOR FOR TREAMENT AND REPORT THE INCIDENT TO THE SOUTHERN NEVADA HEALTH DISTRICT AT 702-759-0677 OR BODYART@SNHD.ORG.

Date:

Signature

Skin Type

Pigment Color

Consultation Date:

Treatment Date:

Top-Up Date:

Location

Treatment Price

Rows	Date Completed
Skin patch test
Pre instructions
After Care instructions
Before photos
After photos

Top Up Price

Eyebrow / Lip / Area Being Treated Photos

Medical Information

General Consent & Procedure Permit

Topical Anesthetic Form

Authorized Use Only