- I understand that I will have permanent and/or semi-permanent cosmetic (referred to on this form as PMU/SPMU) makeup applied using appropriate instruments and sterilizing techniques, that the highest standards of hygiene are met before, during and after the procedure, and that sterile and/or disposable tools and pigment containers are used for each individual client, procedure, and visit.
- I am aware that PMU/SPMU lip procedures may aggravate or trigger cold sores in those susceptible to them, and if I have ever had a cold sore in my life, that I should begin taking the appropriate medication in accordance with my physician's instructions.
- If any unforeseen condition arises during the PMU/SPMU procedure, I authorize the Technician, to use his/her professional judgment in deciding upon what action she feels is necessary in the given circumstances, and I give my consent with my physicians for medical information required/related to the safety of my PMU/SPMU procedures.
- I accept the responsibility for determining and agreeing to the color, shape, and position of the PMU/SPMU procedure as agreed upon during the consultation.
- I understand that an allergy test does not guarantee that I will not develop an allergic reaction to the pigment or the anesthesia
- I fully understand and accept that non-toxic pigments are used during the procedure and that the results will fade over time. Color results and longevity cannot be guaranteed, and even once the color fades, some trace pigment may stay in the skin indefinitely.
- I have been advised that annual touch-ups are encouraged to maintain the integrity of the color. No representations have been made to me as to the ability to later restore the skin involved in my PMU/SPMU procedure to its original condition, and I am aware that it can be costly to remove.
- I have been advised that the true healed color will be visible 1 month after each procedure, and that the pigment may vary according to skin tones, skin type, ethnicity, age, lifestyle, post-procedure care, and general skin condition.
- I understand that some skin types accept pigment more readily, and no guarantee on exact color results can be given.
- I understand and accept that each procedure is a process that may require multiple applications of pigment to achieve desired results, and that 100% success cannot be guaranteed from the first procedure, and that I may have to return for a repeated procedure to achieve my desired results
- The results of any PMU/SPMU procedure are determined by the following factors: medication, skin types/characteristics (dry, oily, sun damaged, thick, thin) Ethnicity, Personal PH Balance, Alcohol intake, smoking, medical conditions (known and unknown) and post-procedure after care. It is not an exact science, and results cannot be guaranteed.
- Upon completion of the procedure there may be some swelling and redness of the skin, which will subside in 1-4 days. In some cases, bruising may occur. I may resume normal activities following the procedure, however, using cosmetics, excessive perspiration, and sun exposure should be limited until the skin has fully healed.
- I know to refer to the aftercare card for more details.
- I agree to follow all pre and post procedure instructions provided and explained to me by the Technician.
- I can confirm that I received a copy of the aftercare instructions.
- I acknowledge that my skin is vulnerable to infection directly after a PMU/SPMU application, and I am to contact my primary physician if signs of infection are present.
- I understand that positioning of my PMU/SPMU procedure(s) can be affected if I elect to have cosmetic surgery, Botox, Restalyne, Juvéderm, or other cosmetic or surgical procedures.
- I am aware that if I am to have an MRI after the procedure, I must tell the radiologist that I have iron oxide permanent cosmetics. If I am a contact lens wearer, I realize that I must keep my lenses out on the day of a PMU eyeliner procedure.
- I agree to accompany the Technician to the emergency room in the event that her/his skin is accidentally punctured with my needle, take a blood test for their safety, and disclose all test results to the Technician.
- If I have had permanent cosmetics performed previously by another technician, I will not hold Twice The Glamm Co., LLC or my technician responsible for any undesirable or unexpected results, allergic reactions, or any other contraindications following this, or any future procedures performed by the Technician at Twice The Glamm Co.
- To my knowledge I do not have and physical, mental, or medical impairment or disability that might affect my wellbeing as a direct or indirect result of my decision to have the PMU/SPMU procedure performed at this time.
- I am aware that permanent cosmetic inks, dyes, and pigments have not been approved by the United States Federal Food and Drug Administration, and that the immediate and/or long-term health consequences of using these products is unknown.
- I consent to the taking of before and after photos for the purpose of record keeping & documentation required by the Technician's insurance company, as well as for educational and advertising purposes.
- If I am unhappy with results, I will not slander Twice The Glamm Co, LLC or any employees of Twice The Glamm Co, LLC in any online forum including but not limited to: Google, Yelp, Instagram, Facebook, and Twitter. I will contact Twice The Glamm to allow them to work with me to find a solution.
- I am 18 years of age or older, not pregnant or nursing, do not have Hepatitis, HIV/AIDS, and am not under the influence of any drug or alcohol at this time.
All medications and medical conditions have been noted accurately and to the best of my knowledge on my medical health form.
Being of sound mind and body, I hereby release and forever discharge the Technician at Twice The Glamm Co, LLC from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my PMU/SPMU procedure. I fully accept any and all responsibility for any consequences that might stem from my decision to have a PMU/SPMU procedure performed by Twice The Glamm.
The facility that the Technician at Twice The Glamm CO., LLC operates out of in Martinez, Georgia is licensed and regulated by Georgia and South Carolina State of Esthetician Boards and Columbia County Health Department. If I am to submit a complaint I may do so at the address listed by phone or mail. Columbia County Health Department Contact - 1930 William Few Pkwy, Grovetown, GA 30813 - (706) 868-3330
Being of sound mind and body, I hereby certify that I have read the above consent and procedure permit form in its entirety, in which the items and explanations therein referred to were made very clear and understandable. I accept full responsibility for any complications which may arise or result from, during or following the PMU/SPMU procedure that I am about to undergo, and any future procedures I elect to receive. I release and discharge the Technician and Twice The Glamm Co., LLC from any and all claims of negligence, damages, or legal actions arising from of connected in any way with my PMU/SPMU procedure. The PMU/SPMU procedure is being performed at my request according to this consent form.