Kendra Neal Studio Client Consent

Kendra Neal Studio

Permanent Makeup (PMU) Client Consent Form

Kendra Neal Studio LLC (hereafter, "the Company") PMU Technician (hereafter, "the Technician") - select your technician:*

Service*

BrowsLipsBrows and LipsPost-Mast. 3D Nipple/Areola

Service Type*

FullInitial touch-upPeriodic touch-upOther

Have there been any changes to your health since your initial visit including pregnancy, medication, or medical treatments?*

YesNo

Please describe the changes to your health*

Location*

Evans, GABrighton, MI

In Michigan, body art facilities may only use topical anesthetics when they are prescribed and delegated by a licensed physician. At this facility, use of topical anesthetic is covered under Standing Order SO-TA-2025-01, signed by Dr. Keri Topouzian, DO (MI License #5101008226).*

Yes, I choose to use topical anesthetic during my procedure, under Standing Order SO-TA-2025-01. I understand the risks, benefits, and limitations, and I consent to its use.No, I decline topical anesthetic. I prefer to proceed without anesthetic, and I understand I may feel more discomfort during my procedure.

Topical Anesthetic Disclosure & Informed Consent

General Information
Topical Anesthetic Cream is used to numb the skin and reduce pain or discomfort during certain cosmetic procedures. The cream contains numbing agents like lidocaine, tetracaine, and epinephrine which temporarily block nerve signals in the area where it is applied.

Contraindications

Patients with the following conditions may not be good candidates for using Topical Anesthetic Cream. Inform your provider if you have any of these:

Pregnancy/breastfeeding
Are taking certain medications that might interact with lidocaine, tetracaine, epinephrine, prilocaine, or similar anesthetics
History of seizures
History of heart disease, irregular heartbeat, or uncontrolled cardiovascular disease
Severe hyperthyroidism
Severe liver or kidney disease
Methemoglobinemia
Glucose-6-phosphate dehydrogenase deficiency
Known hypersensitivity or allergy to lidocaine, tetracaine, epinephrine, prilocaine, or other similar anesthetics
Active skin infections or rashes at the site of application
Large areas of damaged or broken skin

Side Effects and Complications

While Topical Anesthetic Cream is generally safe, it is not without risk. Side effects and complications, though rare, can include but are not limited to:

Redness or swelling at the site of application
Itching or irritation
Mild burning or stinging sensation
Numbness beyond the area of application
Allergic reactions: Rash, itching, swelling, or more severe symptoms
Systemic effects such as dizziness, headaches, or cardiovascular issues
Methemoglobinemia (rare but serious complication)
Potential for toxicity if used improperly or over large areas

Expectations and Results

I acknowledge that while the use of a topical anesthetic is expected to reduce discomfort during my procedure, I may still experience some level of sensation. I understand that there is no guarantee of complete pain relief. The results of using topical anesthetic products can be influenced by many factors, including the area of application, the duration of application, and individual sensitivity.

Prescription, Oversight, and Legal Notice

Ihave been informed that the topical anesthetic used in this facility is applied under the authority of a standing order signed by Dr. Keri Topouzian, DO (Michigan License #5101008226), Standing Order SO-TA-2025-01. This standing order satisfies the requirements of Michigan Body Art Rules 325.2639(5) and 325.2653(8)–(9) and MCL 333.16215, which require that anesthetic use be appropriately prescribed by a Michigan-licensed physician and delegated only to trained technicians.

Per this standing order, my provider is delegated the application of topical anesthetics in accordance with the physician’s written directions, dosage limits, and documentation requirements. The details of the anesthetic used (including product name, lot number, expiration date, dosage, and application time) will be recorded in my client chart and maintained as part of my medical and procedure record.

Alternatives and Consent

I understand that there are alternatives to using a topical anesthetic, including proceeding without anesthetic. After considering my options, I have chosen to use topical anesthetic to manage discomfort during my procedure. I have been fully informed of what this entails, including potential benefits, limitations, and risks, and all of my questions have been answered to my satisfaction. With this knowledge, I consent to the application of topical anesthetic as part of my procedure.

Client Rights and Responsibilities

I understand that I have the right to refuse the use of topical anesthetic at any time before or during the procedure. I agree to notify my provider of any changes in my medical history, medications, or skincare routine between treatments, as these may affect the safety and efficacy of topical anesthetics.

By initialing below, I acknowledge that I have read and understood the information provided above. I understand that topical anesthetic use is prescribed and overseen under Standing Order SO-TA-2025-01 (Dr. Keri Topouzian, DO, License #5101008226) and that my provider’s use of topical anesthetic on me will be documented in accordance with Michigan law. I consent to proceed with the use of topical anesthetic for my procedure.

Initials*

Tattoo Disclosure & Consent
(Including Permanent Makeup / PMU / Body Art Procedures)

For the purposes of this form, the term “tattoo” includes all services performed at this studio involving implantation of pigment in the skin, including permanent makeup (PMU) and other body art procedures.

Procedure Information & Client Acknowledgments
I understand that I will receive a tattoo using appropriate instruments and sterilization techniques. I acknowledge that the highest standards of hygiene are followed before, during, and after the procedure, and that sterile and/or disposable tools and pigment containers are used for each client, procedure, and visit.

If any unforeseen condition arises during the procedure, I authorize the Technician to use their professional judgment in deciding upon any action deemed necessary under the circumstances.

I acknowledge and accept that:

Lip tattoos may trigger cold sores in susceptible individuals. If I have ever had a cold sore in my life, I understand that I am responsible for taking any prophylactic medication recommended by my physician.
I am solely responsible for approving the color, shape, and placement of the tattoo as agreed during consultation.
An allergy test cannot guarantee that I will not develop an allergic reaction to pigments or products used.
Pigments may fade, blur, or change in appearance over time; exact color, symmetry, and longevity cannot be guaranteed. Removal or correction can be difficult and costly.
Final results are visible only after full healing (about one month) and can vary by skin type, lifestyle, age, ethnicity, and aftercare. No guarantee on final appearance can be made. Multiple sessions may be required to achieve the desired result.
Temporary redness, swelling, or bruising may occur.
During healing, I understand that cosmetics, excessive perspiration, direct exposure to water, sun exposure, and dirty or dusty environments should be avoided until the area has fully healed.
I will follow all aftercare instructions provided to minimize the risk of infection, pigment loss, or poor healing results.
I understand that I am vulnerable to infection after a tattoo procedure and will seek medical attention promptly if any signs of infection or other complications appear.
Cosmetic surgery, Botox, fillers, or other procedures after the tattoo may change the appearance of the results.
I must inform medical providers of my tattoos if undergoing MRI.
In the event of accidental needle-stick exposure, I agree to cooperate, including consenting to blood testing for the Technician’s safety.
If I have had prior tattoos, PMU, or body art performed by another provider, I will not hold Kendra Neal Studio LLC responsible for complications or unexpected results.
I am aware that tattoo inks, dyes, and pigments used in this procedure have not been approved by the United States Food and Drug Administration (FDA), and that the immediate and long-term health consequences of their use are not fully known.
I confirm that I do not have any physical, mental, or medical impairment or condition that might affect my wellbeing as a direct or indirect result of my decision to receive a tattoo at this time.
I consent to the use of topical numbing agents during my tattoo procedure. I understand that such products commonly contain lidocaine, tetracaine, benzocaine, prilocaine, and/or epinephrine, and I have disclosed any known allergies or sensitivities to these ingredients to the Technician.
I consent to photos for recordkeeping, training, and marketing purposes.
If dissatisfied with results, I agree to first contact Kendra Neal Studio LLC to allow for resolution before posting public reviews.
I confirm that I am 18 years of age or older, not pregnant, not breastfeeding, and not under the influence of drugs or alcohol at this time.
All medications and medical conditions have been accurately disclosed and noted in my medical questionnaire.
I agree to follow all pre- and post-procedure instructions provided and explained to me by the Technician. I confirm that I have received a copy of the aftercare instructions and the Disclosure and Notice.
All sales are final and non-refundable.
I understand and accept that tattoos are permanent.

I have read this consent form in its entirety, had the opportunity to ask questions, and am voluntarily choosing to receive a tattoo. I accept full responsibility for my decision and knowingly assume all risks described above, including but not limited to infection, allergic reaction, scarring, pigment migration, undesired color or shape, asymmetry, uneven fading, dissatisfaction with results, and the potential need for additional procedures. To the fullest extent permitted by law, I release and hold harmless Kendra Neal Studio, LLC, its owners, employees, contractors, and representatives from any and all claims, damages, or liability arising from or related to the tattoo procedure, except in cases of gross negligence or willful misconduct.

I hereby give my informed consent and authorization for the Technician to perform the tattoo procedure.

The facility that the Technician at Kendra Neal Studio operates out of in Brighton, MI is licensed and regulated by the Livingston County Health Division. If I am to submit a complaint I may do so by contacting Livingston County Health Division at www.lchd.org

LOCATION INFORMATION: 8023 W Grand River Ave, STE 600, Brighton, MI 48114, (706) 480-8870, support@kendranealstudio.com

The facility that the Technician at Kendra Neal Studio operates out of in Evans, Georgia is licensed and regulated by the Columbia County Health Department. If I am to submit a complaint I may do so at the following address by mail or by phone: Columbia County Health Department Contact - 1930 William Few Pkwy, Grovetown, GA 30813 - (706) 868-3330

LOCATION INFORMATION: 2569 Trade Center Dr., Evans, GA 30809, (706) 480-8870, support@kendranealstudio.com

Name*

First NameLast Name

Your date of birth*

Date

Please take a legible photo of your government or state ID:*

Please take a legible photo of your government or state ID

Signature*

Date*

Date

Email*

example@example.com

Phone Number*

Please enter a valid phone number.