Clone of Informed Consent : Permanent makeup

Informed Consent: PERMANENT MAKEUP
Full Name*

First NameLast Name
Phone Number*
Have you ever had tattooed your eyebrows before ?*

YesNoI had and I removed it
Up load a picture of the front of your eyebrows without make up

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Check the conditions that apply to you or to any members of your immediate relatives:

Pregnant Now – Breast Feeding NowAsthmaCardiac diseaseDiabetesCancerHypertensionEpilepsyHIVBlood DisorderHeart ConditionSeizureFaintingAutoimmune DisorderAcne TreatmentBotox around brows ( Last Treatment 3 months ago)Tan by Booth or SalonTumors/ Growths/ CystsTaking Blood Thinners Such As Aspirin, Ibuprofen, Alcohol, CoumadinAllergic Reactions To Medications Such As Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Propylene Glycol, Vitamin E Acetate, ETC.Do You Use Skin Care Products Containing Retin-A, Glycolic Acid, Or Alpha Hydroxy? (Only Applies If You Are Using It On Forehead or Near Brows)
Are you currently taking any medication?*

YesNo
Please List Any Medications You Are Currently Taking :
Do you have any medication allergies?*

YesNoNot Sure
Please List Any Medications Allergies You Are Currently Taking :
Please check your face skin types :*

NormalDryCombinationOilySensitiveAcneAtopic Dermatitis (Eczema)
Have you ever had tattooed your eyebrows before?*

YesNoI had and I removed itOther
Although every precaution will be taken to ensure your safety and wellbeing before, during and after your Permanent Makeup Procedure, please be aware of the following information and possible risks. Please initial:
The nature and method of the proposed permanent cosmetic procedure has been fully explained to me by my technician and / or by her or his associate(s) including the usual risks inherent in the tattooing process, and the possibility of complications during or following its performance. *
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I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur. Additionally fading or loss of pigment may occur. Secondary infection in the area of the procedure may occur; However, if properly cared for, is rare.*
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I have informed my permanent cosmetic technician and / or her or his associates of any and all existing health problems.*
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I acknowledge that complications are always possible as a result of the permanent cosmetic procedure, particularly in the event my post-procedural after care instructions are not followed*
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I acknowledge that hyperpigmentation (darkening of the skin) or Hypopigmentation ( The Absence of color in the skin), or scarring is a possibility as a result of my body's reaction to the skin being broken during the procedure. I realize that my body is unique and that my permanent makeup technician and/or her associate(s) can not always predict how my skin may react as a result of this procedure *
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I understand that successful color saturations cannot be guaranteed due to hidden scar tissue/ skin problems and previous permanent make up or laser treatments around brows.*
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I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results*
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I understand that future laser treatments or other skin altering procedures, such as plastic surgery, implants and injections may alter and degrade my permanent makeup. I further understand that such changes are not the responsibility of my permanent makeup technician. I further understand that such changes in my appearance may not be correctable through further permanent makeup procedures.*
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Due to the fact that my approval is obtained prior to final selection of color to be implanted and design application(s) to be applied, my technician employs a NO REFUND policy*
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For some skin types and procedures, permanent cosmetics maybe a multisession process. In addition to your initial application you are entitled to a post-evaluation appointment. At the post-evaluation appointment it will determine if a touch up to the initial application is required. You must schedule your post evaluation appointment within 4 weeks from the date of the initial procedure.*
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It has been explained to me that immediately after the procedure(s) is completed, the color will appear darker/lighter than when the procedure heals ( depend on my skin type). It has also been explained that within a short period of the time, during the healing process, the color will soften.*
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I have truthfully represented to the technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, metal or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo at this time.*
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All color fades - this is a fact that also applies to pigments/ inks usded for cosmetic tattooing. After your procedure(s) have been performed and any subsequent work performed at the post-procedure appointment, the pristine appearance of your permanent cosmetics is depend on daily maintenance, of avoiding direct sunlight (intentional tanning), avoiding strong chemicals applied to the procedural area, and applying sun block daily ( frequently if in a situation where activities take you into the sun ). Color refreshers will be needed at some point in the future. The time frame for that need cannot be predicted as this aspect of permanent cosmetics is very client specific. If the procedural area is dense enough ( can be easily seen) that one application of pigment/ink will bring the color back to its original appearance, a color refresher fee will charged that represents a lower charge than the fee charged for new work. If the procedural area is extremely light and only represents a weak version of the original procedure, or if it is not visible, a procedure fee for new work in effect at the appointment when the color is reinstated will be charged.*
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I understand that Retin A, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and have exfoliation of the pigment.*
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I acknowledge that obtaining permanent makeup is my choice alone the application if permanent makeup will result in a permanent change to my appearance and that needles and inks will go into my skin . No representations have been made to me as to the ability to later restore the skin involved in permanent make up to the original condition, and it is very costly to remove.*
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I am aware that cosmetic tattooing is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the procedure.*
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I have read and understand the contents of each paragraph above. I have received no un realistic warranties or guarantees with respect to the benefits to be realized from, or consequences of, aforementioned procedures *
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I acknowledge by signing this consent form, I have been given the full opportunity to ask any and all question about permanent makeup procedure(s) and process(es) from my permanent makeup technician and/or her associate(s). I have sisclosed any relevant medical information or conditions that may be a contra-indication to the treatment.*
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I accept the responsibility to explain to you the specific color, shape, and position for any procedure done today prior to starting the procedure.*
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I acknowledge that the proposed procedure(s) involve risks inherent in the procedures and have possibilities of complications during and/or following procedure such as: infection, misplaced pigment, poor color retention and hyperpigmentation.*
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The Style of Permanent Makeup I get today and price ( included promotion):

Nano Hairstrokes by Machine initial appointment $399 (REGULAR PRICE $550)Combination brows initial appointment $399 (REGULAR PRICE $500)Ombre Powder Brows initial appointment $399 (REGULAR PRICE $500)
I acknowledge the the payment today only for Initial Appointment and $150 ( promotion price) 1st touch up after 4weeks *
Initial
I have been advised that a touch up session is required. Touch up must be completed within 4 weeks of initial procedure. It is your responsibility to book your session in a timely manner.*
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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 future application.*
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Price for future touch up (counted at your last touch up appointment) are:

2-5 months touch up $1806-12 months touch up $249Over a year and 6 months full price
I consent to my before and after eyebrow pictures being used on QP Lashes and Beauty’s social media.*
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If this is a previous tattooed eyebrow not performed by QP Lashes and Beauty I understand that QP Lashes and Beauty will not be able to guarantee how well it will hold up or last, due to many factors of your skin receiving previous treatment in the same area.*
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I certify that I have read or have her read to me the contents of this form. I understand the risk and alternative involved in this procedure. I have had the opportunity to ask questions and all of my questions has been answered. I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself.*
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I agree to release and forever discharge and forever hold harmless my technician and its associates, agents officers and shareholders from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoo applied by QP Lashes and Beauty and its associates , agents and representatives in the future.*
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Informed Consent: PERMANENT MAKEUP