PERMANENT MAKEUP REMOVAL CONSENT FORM

PERMANENT MAKEUP SALINE REMOVAL CONSENT FORM
NAME

First NameLast Name
TODAYS DATE

MonthDayYear
Date
DATE OF BIRTH

MonthDayYear
Date
PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
DESCRIBE THE TATTOO THAT NEEDS TO BE LIGHTENED:
LOCATION ON THE BODY WHERE THE TATTOO THAT NEEDS TO BE REMOVED IS:
NOYES (If yes, please list below)
If yes to the question above, please list here:
YESNO
YESNO
YESNO
1. Always burns, never tans2. Always burns, sometimes tans3. Sometimes burns, always tans4. Rarely burns, always tans5. Brown, moderately pigmented skin6. Black skin
For skin types 5 and 6 listed above, I understand that I am at a higher risk of hyper-pigmentation and/or hypo-pigmentation than other skin types. I agree to the risk involved.I understand that several treatments may be needed in order to attempt to achieve my desired results. However, I have not received any guarantees to the quality of the outcome of the process.I understand that there are medical options available for pigment (tattoo) lightening/removal. I have decided to decline those methods.I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen. Scarring as hyper-pigmentation or hypo-pigmentation, discoloration or other damage to the skin may occur during this process and may be permanent. This is rare but it can happen. I will not hold my technician, Lash and Blade and/or the distributor/manufacturer of the tattoo removal products used in the attempted pigment (tattoo) lightening or removal liable for any damages that may occur to my person.I understand there will be no refunds if the desired lightening result is not achieved.I agree to submit to before and after photos, and I give my permission to use such photos for publication and/or teaching purposes.I agree to follow all aftercare instructions provided to me by my technician.I have been fully informed of the natures, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor.There is a fee for this service and an additional fee for all additional sessions. The fees are clearly stated and have been explained to me. I agree to these fees. Fees for the additional session(s) cannot be determined until the results from the first session are complete.I have disclosed all that has been asked of me to the best of my ability and I understand all information listed above. I have had all of my questions answered, and agree to all conditions and provisions of this document as evidenced by my signature below. I accept the risks for having this procedure done, therefore Lash and Blade from any and all liability.
The nature and method of the proposed pigment (tattoo) lightening procedure has been explained to me, including risks and/or possibility of complications during or following the procedure. I understand there may be a certain amount of discomfort or pain associated with the procedure and that the other adverse side effects may include: minor and temporary bleeding, bruising, redness, or other discoloration and swelling. Fever blisters may occur on the lips following lip procedures in individuals prone to this issue. Secondary infection in the area of the procedure may occur, however if properly cared for, this is rare.
SIGNATURE
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PERMANENT MAKEUP SALINE REMOVAL CONSENT FORM