CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE

CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE
CLIENT INFORMATION SHEET
NAME*
ADDRESS*
Phone*
DOB *

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Date
AGE VERIFICATION: Please submit a picture of your ID or Passport.

If you are under 18, please submit Guardian ID as well, and fill out portion below.
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I, First Name Last Name , am over the age of 18 year old ( or under 18 year old but with my guardian approval. Guardian name First Name Last Name Area Code Phone Number.

I 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. First Name Last Name and my guardian First Name Last Name
Procedure Desired
Who referred you and her/ his contact or phone
MEDICAL HISTORY
Are you currently under care of a physician ? *
If yes, why?
Physician's name and phone *
Do you take antibioties when going to the dentist? *
IF YES, WHY?
DO YOU SUFFER FROM:

ALLERGIESMOLES OR FRECKLES AT SITE OF TATTOOHEART PROBLEMSHEMOPHILIADIABETESSKIN PROBLEMSSCARRING (KELOIDS) EYESEPILEPSYPREGNANT OR NURSINGWEAR CONTACT LENSESOTHER
OTHER PROBLEMS, PLEASE EXPLAIN:
ARE YOU PRESENTLY TAKING MEDICATIONS THAT THIN BLOOD?*
ARE YOU TAKING ANY MEDICATIONS? PLEASE LIST:
Have you ever had a cold sore? If yes, you must contact your physician for a prescription of ZOVIRAX capsules, an antibiotic which prevents cold sores. *
I have read the above information regarding ZOVIRAX and understand its use is MANDATORY if I desire lipline or full lip color procedures.
I AGREE THAT ALL THE INFORMATION ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.*

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Date*

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AFTER CARE INSTRUCTIONS FOR PERMANENT MAKEUP

Your skin will be temporarily sensitized after the treatment and you should adhere to thefollowing instructions. This will help avoid infection and allow time for the skin to recover.
For Eyebrows and Eyeliners

Do not use any type of skin care (such as Vascline)

Avoid water for 2 weeks

Do not pick on them when peeling

For Lips

Rinse with salt water after meal for 2-3 days

After 2-3 days, crust will have dried on the lip, apply thin film of the A&D Ointment (or Vascline)with clean Q tips on to loosen crust.

In a rarely situation, you might have blister on the lip, contact your doctor immediately, and you have to pay out of your own pockets.

After the procedure, it is normal for there to be fading the color. At about 6-8 weeks, you should schedule a "touch-up" procedure. This "touch-up" helps the tattoo last longer and encourages the ink to embed more permanently into skin and gave a better result.
I have been provided the proper aftercare instructions both verbally and in writing. Initials*
STATEMENT OF CONSENT & RECITALS
PLEASE READ AND CHECK ALL LINES*

I understand that if anything changes and something happens after the procedure, I will negotiate with the technician to resolve the problem. I will not file the complaint nor sue the technician.I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s).I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit.I accept full responsibility for the decision to have this cosmetic tattoo work done.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 it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergie reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments.I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin.I fully understand this is a tattoo process and therefore not an exact science, but an art.I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s).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 cosmetics.I acknowledge some of these potential adverse changes may not be correctable.I have received pre- and post procedure instructions and I will strictly adhere to such instructions.I understand that my failure to do so may jeopardize my chances for a successful procedure.If I am on any medication for depression or any other mood altering prescription, I will advise my technician.IF I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.By completing and signing this form. I acknowledge that the fees, once charged, are non- refundable.
CLIENT SIGNATURE*

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DATE*

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CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE

CLIENT INFORMATION SHEET

MEDICAL HISTORY

AFTER CARE INSTRUCTIONS FOR PERMANENT MAKEUP

STATEMENT OF CONSENT & RECITALS