Consultation & Waiver Form

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Full Name

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example@example.com

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Street Address

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Normal: Balanced skin that is neither too oily nor too dryDry: Lacks moisture, often feels tight or roughOily: Excess oil production, often shiny with enlarged poresCombination: A mix of dry and oily areas, typically oily in the T zone (forehead, nose, chin) and dry on the cheeksSensitive: Prone to irritation, redness, & reactions to products or environmental factors

PLEASE READ CAREFULLY

- Permanent cosmetics are a form of tattooing.
- Touch-up(s) procedures may be required.
- A healing period of 4 to 6 weeks is required before any touch-up procedure can be performed.
- On rare occasions the pigment may migrate under the skin.
- Application of permanent cosmetics can be uncomfortable.
- The pigments will fade.
- Immediately after the procedure, the pigment can be 30 to 50% darker than the desired result.
- There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare.
- A negative allergy test result will not guarantee that you will not have an allergic reaction.
- Infections can occur if aftercare is not followed.
- Allergic reactions to anaesthetics can occur.
- There may be swelling and redness following the procedure.
- You may experience minor bleeding.
- If you have a MRI scan within 3 months your permanent cosmetics procedure we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.

I have read and understand the above statement (please initial)

Please upload a clear, full photo of your face

Please list and name all medications taken within the last 6 months

In the last 48 hours, have you taken any of the following

Rows	YES	NO
Aspirin
Ibuprofen
Coumandin/Anticoagulant
Alcohol
Caffeine

Have you ever had an allergic reaction to any of the following

Rows	YES	NO
Anaesthetics
Adrenaline
Foods
Medication
Glycerine
Lidocaine
Any allergy not listed

If 'yes' to an allergy not listed, please provide additional information below

Have you received chemotherapy or radiation treatment in the last year?

Please select yes to the following that apply to you

Rows	YES	NO
Abnormal Heart Condition
Cold Sores (herpes simplex)
Mitral Valve Prolapse
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Diabetes
Fainting Spells or Dizziness
Cancer
Tuberculosis
Stroke
HIV
Hepatitis
Alopecia
Recent Hair Loss
Chapped Lips
Trichollomania
Botox Injections
Keloid Scars
Scar Easily
Healing Problems
Bruise or Bleed Easily
Sensitivity to Cosmetics
Use of tanning bed
*Accutane within 6 months
*Cortisone within 6 months
*Chemical or laser peel within 6 months
*Retin A/tretinoin within 6 months
AHA preparations within last 2 weeks

1. I hereby authorize [Laura O'Callaghan] (Technician) of [Face & Ink Co.] to perform the listed treatment upon myself.

2. If any unforeseen condition arises in the course of this procedure(s), calling in their judgement or different from those now observed, I further request and authorize the technician to do whatever they deem advisable and necessary in the circumstances.

3. I accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation.

4. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment.

5. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade between 1-3 years.

6. I have been informed that the highest standards of hygiene are met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit.

7. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results and that 100% success cannot be guaranteed. I understand this is why I need to return for a retouch procedure.

8. I understand that a retouch procedure should be performed 1-3 months (recommended 6-8 weeks) after the initial procedure, and after a 3-month period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties.

9. The result of the procedure is determined by the following:
- Medication
- Skin characteristics (dry, oily, sun-damaged and thickness)
- Natural skin undertones (blending with chosen pigment)
- Personal pH balance of skin, which changes from visit to visit
- Alcohol intake and smoking
- Post procedure care treatment

10. Upon completion of the procedure there may be some swelling and redness, which should subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately following the procedure, however, using cosmetics, excessive perspiration, water and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. Rest assured after only one treatment, you should feel comfortable without additional makeup on the affected area.

11. I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment colour may vary according to skin tone/type/conditions and age. I understand that some skin absorb pigment more than others and no guarantee to an exact effect or colour can be given.

12. To my knowledge I do not have any physical, mental or medical impairment that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol, pregnant or breastfeeding.

13. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician.

14. Being of sound mind and body, I hereby release any and all responsibility. I accept all responsibility for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by [Laura O'Callaghan] (Technician)

15. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the procedure(s).

I have read and understand the above statement (please initial)

ALLERGIC REACTION

– Allergic reaction can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction responses may display a rash, redness, itching, swelling, blistering, dryness or any other symptom associated with the allergy.
- We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is completely numb while others say they experience some discomfort.

PROCEDURE

– For all procedures a cream or gel topical anaesthetic is used. These products are safe, and can be purchased over the counter. The anaesthetic is placed over the treatment area for between 5-20 minutes, then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between 1-4 hours. You should always follow your post procedure instructions.

I have read and understand the above information (please initial)

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