DOB

Name

First NameLast Name

DATE

Date

ADDRESS

DOB:

Date

PHONE

Format: (000) 000-0000.

EMAIL

example@example.com

I, First Name Last Name am over the age of 18, 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.

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 its known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to infection, allergic reaction, scarring, inconsistent color, spreading, fanning, or fading of pigments.I understand that the taking of before and after photographs of the said procedure(s) is a condition of such procedure(s). I certify that I have read and initiated the above paragraph and have explained to my understanding this consent and procedure permits. I accept full responsibility for the decision to have this cosmetic tattoo work done.If I have any condition that might affect the healing of this tattoo. I will advise my practitionerI am not pregnant or nursing, and/or under any influence of drugs or alcohol.I do not have medical or skin conditions such as but not limited to acne, scarring (Keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection, or rash anywhere on my body, I will advise my practitioner.I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risks that such a reaction is possible.I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence will be done at my own expense.I realize that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.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 to my tattoo.I acknowledge that a tattoo, also known as body art, is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo.To my knowledge, I do not have a physical, mental, or medical impairment or disability, which might affect my well-being as a direct or indirect result of my decision to have a tattoo.I acknowledge that tattoo inks, dyes, pigments have not been approved by the Federal Food and Drug Administration (FDA), and the health consequences of using these products are unknownI acknowledge that I am over the age of eighteen (18), and that I have truthfully presented to my tattooer, and that obtaining a tattoo is by my choice alone.I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure

Do you have any of the following: (check Yes or No)

Rows	YES	NO
Pregnancy
Breastfeeding
Diabetes
Hepatitis
Forehead/Brow lift
Easy bleeding
Alcoholism
Abnormal heart condition
Take medication before dental work
Chemical peel
Botox
Autoimmune disorder
Oily skin
Cancer
Accutane or acne treatment
Chemotherapy/radiation
Tan by booth or salon
Tumors/ Growth/ Cysts
Difficulty numbing with dental work
Regular use skincare products containing Retin-A, Glycolic Acid, or any Acid
Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin, etc
Allergic reaction to any medication such as lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Latex?

Last Botox treatment:

Hepatitis A, B, C or D?

Last Chemical Peel:

Cancer: (year)

Current medication:

Signature

Date

Signature   Aftercare instructions have been explained to me and a written copy may be given to me upon request to retain in my possession, which I will follow to the best of my ability
Signature   I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness, an/or bruising may occur.
Signature   I understand that Retin-A, Renova, Alpha Hydroxy, And Glycolic Acid must not be used on the treated areas, they will alter the color and cause premature exfoliation of the pigment.
Signature   I understand that tanning beds, pools, some skincare products and medications may affect my permanent makeup.
Signature   I understand that successful color saturation CANNOT be guaranteed due to hidden scar tissue.
Signature   I will tell all skincare professionals or medical personnel about my permanent makeup procedures especially if scheduled for an MRI.
Signature   I accept the responsibility to explain to you my desire for specific color, shape and position for any procedure today.
Signature   I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with the future applications and a touch-up session within 60 days.
Signature   I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedure(s) such as the following: infection, misplaced pigment, poor color retention, and hyper-pigmentation.
Signature   I have been quoted the cost of today's appointment and the cost of the touch-up by Evelyn Araujo at The Pink Room. Touch-ups must be completed within 6-12 weeks of the initial procedure to be considered a touch-up price.
Signature   I understand that my photos may be taken before and after the procedure, and I approved Evelyn Araujo at The Pink Room to use my photos for any marketing purposes
Signature   I understand that there are NO refunds under any circumstance.
Signature   I certify that I have read the contents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize The Pink Room to perform on my eyebrow procedure(s) desired today.

Signature

Date

Ombre Brow New Treatment Client Consent Form

Client Information

MEDICAL HISTORY

If you answered yes to any of the above please explain:

Statement of Consent and Recitals (please read and initial all lines)