Permanent Cosmetics Informed Consent and Release

Permanent Cosmetics Informed Consent and Release
Scalp MicropigmentationScar CamouflageUpper EyelinerLower EyelinerFull EyebrowsPartial EyebrowsFull Lip ColorLip LinerBeauty MarkBB Glow Micro NeedlingOther
In consideration of receiving a Permanent Cosmetic Procedure (PCP) at Advanced Clinical Aesthetics from: (Practitioner Name) blanks* , together with its personnel, apprentices and independent agents or guests of the "facility", in the state of California, I AGREE TO THE FOLLOWING.
That I, blanks* (PRINT your name) have been informed of the inherent risks associated with getting a PCP. 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, allergic reaction, scarring, inconsistent color and spreading, fanning or fading of pigments, nerve damage, difficulties in detecting melanoma, latex gloves, and/or soap allergies. Body art procedures may cause swelling, bruising, discomfort, bleeding, and pain. Body art procedures may also cause irreversible changes to the human body. Donating blood may be prohibited after receiving a procedure. I understand the actual color of the applied pigments 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).
Intitials*
To Waive and Release to the fullest extent permitted by law each of the Practitioners and the “Facility” from all liability whatsoever for all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my Permanent Cosmetic, whether caused by the negligence or fault of either the Practitioner, Facility, or otherwise.
Initials*
I understand that if I have any other skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetic site. I acknowledge that it is possible that these potential adverse changes may not be correctable.
Initials*
I have received verbal and written suggested aftercare instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chance for a successful procedural outcome. I acknowledge that it is possible that the PCP site may become infected, especially if I do not follow the suggested aftercare instructions given to me. I agree that it is my responsibility to contact the Practitioner or Facility if there are signs or symptoms of infection including, but not limited to, significant swelling or tenderness of the procedure area, red streaks going from the procedure area towards the heart, elevated body temperature, or purulent drainage from the procedure area. If any touch-up work to the PCP is needed due to my own negligence, I agree that the work will be done at my own expense.
Initial*
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.
Initials*
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to the application of a Permanent Cosmetic Procedure by the Practitioner without duress or coercion.
Initials*
That the Practitioner or the Facility representative has given me the full opportunity to ask all questions about the application of my Permanent Cosmetic (Tattoo) Procedure and all my questions have been answered to my complete satisfaction.
Initials*
Tattoo Inks and Pigments have NOT been approved by the FDA and the health consequences of using these products are unknown. We follow all applicable regulations and standards as required by OSHA and local regulatory agencies.
Client Information

All information gathered from the client that is personal medical information and that is subject to the federal Health Insurance Portability Accountability Act of 1996 (HIPPA) or similar state laws shall be maintained or disposed of in compliance with those provisions.
Referred By:*
YesNo
If yes, explain
Physician*
General Medical
YesNo
If yes, explain
YesNo
If yes, explain
I have not taken blood-thinning or anticoagulant medication in the last 72 hours (Example: aspirin, ibuprofen, coumadin, alcohol, vitamin E)I have not taken Accutane within the last 6 monthsI have not had surgery of any kind in the last 6 monthsI have not had Botox or other cosmetic filler procedures within the last 2 weeksPregnant or nursingDiabetesHigh blood pressure or faintingCardiac valve diseaseHemophiliaMitral valve prolapses, valve implants, organ or bone marrow transplantHeart palpitations or other heart condition
YesNo
If yes, which type?
Date
YesNo
If yes, describe
YesNo
If yes, describe
List previous cosmetic/other surgeries*
If planning cosmetic or other surgery in the near future, please describe*
List all medications, prescription and non-prescription, taken in the last 2 weeks*
Allergies
LanolinAntibioticsAntibiotic ointmentLidocaineRubber-LatexPABA
Metals (which ones)
Other allergies*
Describe Reactions*
Skin
Tattoos: locations and age*
YesNo
YesNo
I understand that sun exposure, tanning beds, pools, some skin care products and medications may affect the desired outcome of my permanent cosmetic procedure.
YesNo
I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas as these products will alter the pigment colors used for my treatment.
YesNo
If yes, date(s)
Type of peel
YesNo
If yes, location(s) and age(s) of scar(s)
YesNo
If yes, location(s)
YesNo
If yes, explain
YesNo
If yes, explain
YesNo
If yes, explain
Eyes / Eyebrows / Scalp
Dry EyesBlurred VisionGlaucomaEye Cosmetic Sensitivities
Other Eye Disorders*
YesNo
Eyebrow tinting? - Date of last service*
Eyelash tinting? - Date of last service*
Hair tinting? - Date of last service*
YesNo
YesNo
Other hair loss conditions? Please describe*
Lips
YesNo
If yes, please contact your physician for an anti-viral medication and initial this disclaimer:

“I will consult with and strictly follow my physician’s instructions before contemplating any permanent cosmetic procedure around my lips.I have received information from my physician about anti-viral medication and understand its use is mandatory if I desire lip liner or full lip color procedures.”
Initials*
This history has been reviewed by the practitioner and my questions have been satisfactorily answered. I have reviewed and been offered a copy of this Informed Consent and Release form and written suggested aftercare instructions, understand them and agree to follow them.
YesNo
YesNo
Location of Collagen injections
YesNo
Location of Fat transfer injections
YesNo
Location of gore-tex injections
This history has been reviewed by the practitioner and my questions have been satisfactorily answered. I have reviewed and been offered a copy of this Informed Consent and Release form and written suggested aftercare instructions, understand them and agree to follow them.
Client Name*

First NameLast Name
I hereby declare that I am of legal age, have provided valid proof of age, and am competent to sign this Agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT. ALL SALES FINAL.
Client Name*

First NameLast Name
DOB*
Today's Date*

MonthDayYear
Date
Time of Day*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Should be Empty:

Permanent Cosmetics Informed Consent and Release

Client Information

General Medical

Allergies

Skin

Eyes / Eyebrows / Scalp

Lips