Cosmetic Tattoo Consent Form

Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my abilities. If I have any questions I will call or email you.

I understand that a certain amount of discomfort is associated with this procedure and the swelling and redness may occur.

I understand that Retin-A, alpha hydroxy, and glycolic acids must not be used on the treated areas, they will alter the color.

I understand that sun, tanning beds, pools and some skin care products can affect my permanent make up.

I accept the responsibility for my explanation to you, my desire for a specific color, shape, and position for any procedure done today.

I understand the implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I need to maintain the color with future applications and a touchup session within 4 to 8 weeks.

Iacknowledge that the proposed procedure involves risk inherent in the procedure and have

possibilities of complications during and/or following the procedures such as infection, misplaced pigment, poor color retention, and hyper pigmentation.

I have been quoted the cost of today's appointment and will come back for my mandatory 4 to 8 week touchup. There will be no refunds for this procedure.

I certify that I have read the contents of this form. I understand the risks and alternatives

involved in this procedure, and 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. I authorize Stephanie Pascarella as my cosmetic tattoo technician to perform on my body the procedure desired today.

Have you had or currently have any of the following

Had history of Methicillin-resistant Staphylococcus aureus (MRSA)

Had undergone Chemotherapy/ Radiation

Taking or have taken acne treatments in the past year

Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc

Allergic reaction to any medications

Allergies to metals, food, etc,

Any diseases other than listed here

Do you use facial care treatments like chemical peels?

Do you use Retin-A, glycolic acid, or alpha hydroxy?

Have you ever had a cold sore outbreak?

Please list any medications you are taking:

I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and I

consent to receiving the cosmetic tattoo procedure. I have been informed and it was explained to me the general nature of tattooing as well as the specific procedure to be performed.

I have been informed of the possible risks and consequences of tattooing and I understand that

there might be complications and consequences associated with this procedure, such as: infection, scarring, or inconsistent color.

I understand that this procedure might result to fading in time. I have likewise received and will strictly adhere to procedural instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my responsibility.

I have the option to do a patch test to identify any allergic reaction to any medicine or anesthetics. Should I waive for the test, I release the technician from liability if I develop an allergic reaction to any of the procedure.

I understand that photographs taken for comparison of the before and after procedure are part

of the said procedure. I give consent for my before and after photos to be posted on Instagram or other forms of social media and may be used in my technician's portfolio.

I accept full responsibility for the decision to have this tattoo procedure done. The cost for touch-up's after this first procedure are not included.

Infection is very unusual. The areas treated must be kept clean and only freshly clean hands to

touch the areas. See the aftercare sheet for instructions on the care.

Uneven pigmentation can result from poor healing, infection, bleeding, or many other causes. Your follow up appointment will likely correct any uneven appearance.

For microblading, every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustment may be needed during the follow up session to correct any

Anesthetics are used to numb the area to be tattooed. Lidocaine in a cream or gel form is typically used. If you are allergic, please inform me now.

Although tattooing is effective in most cases, no guarantees can be made that a specific client will benefit from this procedure.

This is the process of inserting pigment into the skin and is a form of tattooing.

All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross-contamination guidelines are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touchup after the healing is completed.

For eyebrows and lips: Initially the color will appear much more vibrant or darker compared to the end result. Usually within 5 to 8 days the color will fade at 40 to 50%, soften, and look much more natural. The pigment is semi permanent and will fade over time. It will likely need to be touched up within 6 to 18 months.