CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETICS

This form is designed to give information needed to make an informed choice of whether to undergo a permanent cosmetics application. If you have questions, please don't hesitate to ask. Although permanent cosmetic tattooing is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

Company Name: Luna Luxe Beauty Lounge, LLC

Permanent cosmetic tattooing ("Permanent Cosmetics") is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines and best practices are strictly adhered to. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed. Initially the color applied will appear much more vibrant or darker compared to the end result. Over a period of 5-14 days the color will fade 10-50%, soften and look more natural. The pigment is permanent but will fade somewhat over time and will likely need to be touched up through the years.

I give permission to Luna Luxe Beauty Lounge, LLC licensed professionals to perform the procedure we have discussed and will hold her/him harmless for any liability that may result from this treatment. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions, or medications at the time of my service. I am allowing the professional to use and/or apply any necessary chemicals as part of the service I am recieving.

I understand it is out of scope for the esthetician, permanent makeup artist, and nail technician to diagnose health conditions or to give any medical advice.

I understand that my data will be strictly confidential and the Luna Luxe Beauty Lounge, LLC does not sell, share, or resell information. 

I confirm that all information in this form is true and accurate.

I confirm that if I withhold some important information and complications happen, that the Luna Luxe Beauty Lounge, LLC will not be liable. 

I release Luna Luxe Beauty Lounge, LLC and hold them harmless against any claims, expenses, damages, and liabilities.

I understand that Luna Luxe Beauty Lounge, LLC will not be held accountable for any damages, loss, injury, death, and accidents from myself and for my unsupervised children.

I agree that if I take any steps to make any claims for damages against Luna Luxe Beauty Lounge, LLC I shall be obligated to pay all attorney fee's and costs incurred as a result of such claim. 

Cancelation Policy:

I understand that Luna Luxe Beauty Lounge, LLC has a cancellation policy.

I understand that I have to give a 24 hour notice should I need to cancel my appointment.

I understand and accept that  if i am late to my appointment by more than 15 minutes, I am subject to a 50% charge of all services scheduled for that appointment. No calls and no shows will result in a 100% service charge. This is non refundable. 

I agree that Luna Luxe Beauty Lounge, LLC reserves the right to cancel and/or reschedule my appointment if I present myself with any health conditions that may be contraindicated, or scheduled services. This may include health conditions that the technician decides may need oversight by a medical professional, and scheduled services will be canceled until condition is resolved! 

*I accept and understand everything within the terms and conditions above. I confirm that I give Luna Luxe Beauty Lounge, LLC my consent to perform services and the information given above is correct and true to the best of my knowledge.

 

PHOTOGRAPHY AND VIDEOGRAPHY RELEASE CONSENT

We reserve the right to take "Before" and "After" photos/videos to be kept on file. We would like your permission to use these photos/videos for advertising. For example, in portfolios, online and in print ads, etc. Your consent is necessary for us to use your photos/videos in our advertising and promotional materials.

POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS

• Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. Every attempt to make you comfortable during the service will be made.
• Infection: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the treated areas. See "After Care" sheet for instructions on care.
• Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance.
• Asymmetry: Every effort will be made to avoid asymmetry, but our faces are naturally not symmetrical, so adjustments may be needed during the follow-up session to correct any unevenness.
• Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help, and the bruising and swelling typically disappear within 1-5 days. Some people don't bruise or swell at all.
• Eye Exposure: There is a small risk of eye injury when an eyeliner procedure is performed. Special methods and procedures are used to avoid corneal abrasion and protect the eye prior to the procedure. Eye drops are also used to cleanse and flush the eye after the procedure is complete.
• Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these, please inform your technician before the procedure.
• MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low-level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.
• Fever Blisters: If you are prone to cold sores or fever blisters, (herpes simplex), there is a high probability that you will get them. It is advised that you call your doctor for a prescription antiviral to help prevent this from occurring.
• Allergic Reaction: There is a small possibility of an allergic reaction. You may take a patch test (5-7 days) to determine this.

The alternative to these possibilities is to use cosmetics and not undergo the Permanent Cosmetics procedure. By signing below, I acknowledge that I have read and understand the risks involved in the Permanent Cosmetics procedure to be performed by an approved Permanent Cosmetics technician of the Company.

STATEMENT OF CONSENT AND RECITALS

Please read, sign, and date at the bottom:

• 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 ability. If I have questions I will call or email you.
• I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness, and bruising may occur.
• I understand that sun, tanning beds, pools, some skin care products, and medications can affect my Permanent Cosmetics.
• I will tell all skin care professionals or medical personnel about my Permanent Cosmetics procedures, especially if I’m scheduled for an MRI.
• I accept the responsibility for explaining to you my desire for specific colors, shapes, and positions for any procedure done today.
• I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 60 days.
• I acknowledge that the proposed procedure(s) involve inherent risks and have possibilities for complications during and/or following the procedures, such as: infections, misplaced pigment, poor color retention, and hyperpigmentation.
• I am not under the influence of alcohol or drugs.
• I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing excluded).
• I acknowledge that I am not pregnant.
• I acknowledge that I am free of communicable disease.
• I acknowledge that I have truthfully represented to the associates, agents, and representatives that I am over eighteen (18) years of age.
• I acknowledge it is not reasonably possible for the associates, agents, and representatives to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and I agree to accept that such risks are possible, even if I have taken a patch test.

• I acknowledge that infection is always possible as a result of obtaining a Permanent Cosmetics tattoo, particularly in that event that I do not take proper care of the affected area, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care.
• I acknowledge receipt of written instructions advising me of proper care of my Permanent Cosmetics tattoo and recognize the absolute necessity of following those written instructions. All questions about the Permanent Cosmetics procedure have been answered to my satisfaction.
• I acknowledge that variations in color may exist between any pigment selected by me and as ultimately applied to my body.
• I acknowledge that Permanent Cosmetics is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter, or remove my Permanent Cosmetics tattoo.
• I acknowledge that agreeing to this Permanent Cosmetics procedures is my choice alone, and I consent to the application of the Permanent Cosmetics tattoo and to any actions or conduct of the associates, agents, or representatives of the Company that are reasonable and necessary to perform the Permanent Cosmetics procedure.
• I agree to release and forever discharge and forever hold harmless the Company and its associates, agents, officers, and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my Permanent Cosmetics tattoo or the procedures and conduct used to apply my Permanent Cosmetics tattoo and any and all Permanent Cosmetics tattoos applied by the Company and its associates, agents, and representatives in the future.
• I acknowledge that Permanent Cosmetics inks, dyes, and pigments have not been approved by the federal Food and Drug Administration (FDA) and the health consequences of using these products are unknown.
• I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy, and/or faint before, during or after the procedure.
• I agree to follow all instructions concerning the care of my Permanent Cosmetics tattoo and that any touch-ups needed because of my own negligence will be done at my own expense.

By signing below, I agree and acknowledge that I have been fully informed of the risks of the Permanent Cosmetics procedure, including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics.

I certify that I have read or have had read to me the contents of this form. I have had the opportunity to ask questions, and all my questions have been answered.

I acknowledge that I have reviewed and approved the material given to me, and I authorize Luna Luxe Beauty Lounge, LLC as my Permanent Cosmetics technician, to perform the selected service on my body. Having been informed of the potential risks associated with getting Permanent Cosmetics,

I still wish to proceed with the procedure, and I assume any and all risks that may arise from the Permanent Cosmetics procedure.

AFTERCARE

Aftercare is very important for producing a beautiful and lasting result when receiving a Permanent Cosmetics procedure.

• Keep the area clean by washing with freshly washed hands and mild soap. Do not use a washcloth or sponge to remove soap. Simply splash with water. Do not use cleansing creams, acne cleansers, or astringents. Use a mild, natural soap.
• Apply the aftercare balm with freshly washed hands or a Q-tip. If the balm is too stiff to use, simply warm it up in a glass of warm water or on your finger. Use the balm very sparingly. Too little is better than too much. Blot off excess with a clean tissue.
• Never touch the procedure area without washing your hands immediately before.
• Do not scrub, rub, or pick at the epithelial crust that forms. Allow it to flake off by itself. If it is removed before it is ready, the pigment underneath it can be pulled out.
• Do not use any makeup near the procedure area, including mascara for eyeliner procedures, for at least 3 days. Purchase new mascara and makeup if possible to avoid contamination or bacterial infection.
• Always use sunblock after the procedure area is healed to protect from sun fading.

What's Normal?

• Swelling, itching, scabbing, light bruising, and dry tightness. Ice packs are a nice relief for swelling and bruising. Aftercare balm helps with scabbing and tightness.
• Too dark and slightly uneven appearance. After 2-7 days, the darkness will fade. Once swelling dissipates, the unevenness usually disappears. If the treated area is too dark or is still a bit uneven after four (4) weeks, then we will make adjustments during the touch-up appointment.
• Color change or color loss. As the procedure area heals, the color will lighten and sometimes seem to disappear. This can all be addressed during the touch-up appointment and is why the touch-up is necessary. The procedure area must be completely healed before we can address any concerns. This takes at least four (4) weeks.
• Needing a touch-up months or years later. A touch-up may be needed 1 to 5 years after the initial procedure depending on your skin, medications, and sun exposure.

Failure to follow aftercare instructions may result in infections, pigment loss, or discoloration.

I have read, understand, and agree to the above instructions and information regarding aftercare and what is normal.

NOTE: Permanent makeup is NOT recommended for any clients who are/have:

-Pregnant or nursing

-Diabetic

-Undergoing Chemotherapy (consult your doctor)

-Viral infections and/or diseases

-A Pacemaker or major heart problems

-Had an organ transplant

-Skin irritations near the treated area (rashes, sunburn, acne, etc -Sick (cold, flu, etc

-Had Botox in the past 2 months

-Used Accutane in the past year

I agree that all the above information is true and accurate to the best of my knowledge.