Cosmetic Tattoo Consent Form
Client Information
Name
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First Name
Last Name
Age
*
Birth Date
*
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Day
-
Month
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
*
Please enter a valid phone number.
Cosmetic Tattoo Procedure(s) desired:
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Full Eyebrows
Lip Line & Blend
Select if you have ever had an allergic reaction to any of the following.
Lanolin
Latex Rubber
Lidocaine
Foods
Novocaine
PABA
Metals
Other drugs
Dental injections
Other
Please describe the allergic reaction you had to any of the above.
Select any of the following conditions which apply to you.
Glaucoma
Cataracts
Blurred vision
Dry eyes
Thyroid abnormalities
Eye makeup sensitivities
Alopecia
Have experienced other hair loss
Pulling out Lashes or Eyebrows compulsively? (trichotillomania)
Recent Eyebrow tinting
Recent Eyelash tinting
I have an eye disorder
Any facial Collagen/Restalyn injections in the last 48 months
Botox injections in the last 48 months
Fat transfer injections in the last 48 months
Laser Resurfacing / Laser Hair Removal in the last 48 months
Please detail any of the above you may have ticked.
Do you or have you ever suffered from any of the following?
Cold sores
Fever blisters
Mouth ulcers
Herpes around the mouth
Chapped lips
Chicken pox
Chingles
If YES, what medication have you been taking prior to eyebrow procedure
Do you have any keloid or hypertrophic scars? Where and how old?
Any healing problems?
Do you have any other active dermatological disorders, such as Eczema, Dermatitis, Psoriasis, Rosacea, Acne, and Skin Cancers?
Do you bruise or bleed easily?
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Yes
No
Select any of the following conditions which apply to you.
I am a smoker. (Healing is slower for smokers)
High blood pressure
Low blood pressure
Taking blood thinners or anticoagulants such as Aspirin, Ibuprofen, Coumadin, Alcohol
Diabetic (A letter from your Doctor is required before going ahead with a CT Treatment)
Haemophilia or other clotting disorders (Prolonged Bleeding)
Seizures
Pregnant or Nursing a Baby
Mitral valve prolapse or valve implants (A letter from your Doctor is required)
Heart palpitations
Taken Accutane within the last 6 months (Skin is not suitable to Tattoo for 6 months post)
Autoimmune disorders.
HIV positive
Signed Date
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Day
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Month
Year
Date
Client Signature
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Practitioner Signature
*
CONSENT AND PROCEDURE PERMIT FOR A COSMETIC TATTOO TREATMENT
*
I am aware from reading the treatment information that the treatment has been in Australia for over 23 years and you have no knowledge of any consequences which may follow from such treatment.
I present to POWBROW Cosmetic Tattoo that I am over the age of 18 and desire them to perform the elective cosmetic tattoo procedure, understanding that this procedure is for cosmetic purposes only. If any unforeseen conditions arise in the course of this procedure calling for your judgment for procedures in addition to, or different from those now contemplated, I further request and authorise you to do whatever necessary in the circumstances. I am aware that NO GUARANTEES HAVE BEEN MADE TO ME CONCERNING THE RESULTS OF THE PROCEDURE.
I also understand that a Cosmetic Tattoo Procedure can carry possible complications, risk of infection, scarring, eye damage, inconsistent colour, bruising, and possible spreading and fading of pigments, with few known allergic reactions after the treatment and if instructions at the time of the treatment and at home are not followed. I understand the actual colour of the pigment may change due to blacks turning a dark blue or grey and due to the tone and colour of my skin. I fully understand as with all such procedures that this is not a science but rather an art. I request the CosmeticTattoo procedure, appreciating and accepting the permanency of the procedure whether it be for some months, years or forever as well as the possible complications with few known allergic reactions and consequences of the said procedure.
I acknowledge that you will carry out the treatment at my request and in consideration of the same that in the event that any damage is caused to my skin or any part of my face and or body by the treatment that you will not be responsible for the same and that I shall not be entitled to take any action against you either at Law or in Equity in respect for such treatment.
I acknowledge that I have been given and have availed myself of the opportunity to ask any questions relating to the treatment and that any questions which I have asked were answered to my satisfaction. I am in good health and have no knowledge of the contraindications stated in the History Form.If I do I have had medical clearance by way of a letter.
The following is for your information and I acknowledge that I cannot donate blood to the Blood Bank for the ensuing Twelve Months from today because of the Tattoo. Their question sheet asks, "Have you received a Tattoo or had Electrolysis in the last twelve months ". This Cosmetic TattooProcedure is classed as a Tattoo, as the skin is pierced like electrolysis or body piercing.
It is obligatory for the purpose of our documentation of procedures that I consent to the taking of before, during and after photographs of myself showing the procedure. I authorise POWBROW to use any photographs of myself for whatever purposes deemed necessary
I understand the Cosmetic Tattoo procedure, the procedure, the possible permanency of the procedure, the possible consequences of adding of colour, colour changes, blacks taking on blue or grey hue, and the procedure is for cosmetic enhancement purposes only. I hereby authorise POWBROW to perform the Cosmetic Tattoo procedure.
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 permanent cosmetic tattoo treatments. I acknowledge some of these potential adverse changes may not be correctable.
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I agree that I have a duty to disclose to you every matter that I know or could reasonably be expected to know that is relevant to your decision whether to accept me as a client for the proposed Cosmetic Tattoo/Body Tattoo procedure.
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I CERTIFY THAT I HAVE READ THE ABOVE PARAGRAPHS AND HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND I ACCEPT FULL RESPONSIBILITY FOR THESE AND/OR ANY OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE COSMETIC PROCEDURE WHICH IS TO BE PERFORMED AT MY REQUEST. ACCORDING TO THIS CONSENT WERE FILLED IN BEFORE I SIGNED THIS STATEMENT. I FURTHER AGREE THAT THESE PERMIT AND CONSENT FORMS ARE CONFIDENTIAL AND REMAIN THE SOLE PROPERTY OF POWBROW COSMETIC TATTOOING STUDIO.
SHAPE - COLOUR TOPICAL ANAESTHETIC. CONSENT FORM
In your own words write exactly what you want from the treatment, include any fears you may have regarding the treatment;
*
*
I certify that I have been given the opportunity to change the shape, the final shape I agree, is my choice which will be followed.
*
Colours have been discussed and shown to me by POWBROW. I certify that we have agreed on the colour choice.
*
It has been explained to me that it is my request to have a lighter colour implanted for eyebrows and it has been made clear to me the importance of having the adjustment appointment within 4 months from the initial treatment- The longevity of a lighter colour and thin brows implanted is substantially less than stronger darker pigments suggested within 15 months.
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I do not have any known allergies to local anaesthetic creams or PABA (sunscreen). I know no reason why I cannot receive a topical anaesthetic cream, gel or liquid to prevent or reduce discomfort during my procedure. I have never had any adverse reaction to local anaesthetics administered in aDentist's office during surgical procedures. I understand that there is a wide variation in effectiveness and duration of topically applied anaesthetics with each person.
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I hereby request the use of a topical anaesthetic preparation which contains Lidocaine, Procaine, Tetracaine and Epinephrine. I understand that I may experience redness, itching, swelling or tenderness with the use of a topical anaesthetic. Local anaesthetic preparations are used in sunburn, nappy rash, poison oak/ivy, haemorrhoid and many preparations available at the Chemist over the counter. I also understand and agree that complication scan occur during a Cosmetic Tattoo Procedure and I will follow the instructions of my Practitioner to seek treatment. I accept the use of a topically applied anaesthetic at my own risk for the elective procedure of a Cosmetic Tattoo procedure. I have supplied my own over the counter anaesthetic and applied myself, I hereby give permission to POWBROW to re-apply the numbing products as required during the tattoo treatment and have accepted full liability should I develop a reaction to the numbing agents.
*
I have read the Home Care Information Sheet and the Home Care Instructions. I will follow the instructions for maximum results and I agree to use the recommended products.
I AGREE TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Tattoo Studio from all liability. All claims or causes of action that I may have for personal injury or otherwise, including any direct and/or consequential damages, have not been caused by the negligence or fault of any of the Artists or the Tattoo Studio.
I have read and understood the information that has been provided and I am consenting to be tattooed of my own free will. I do hereby release Neale Cheetham, the Artists and any other person acting on behalf of South West Tattoo from any responsibility or liability.
Signed Date
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Day
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Month
Year
Date
Client Signature
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Practitioner Signature
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