Permanent Makeup Consent Form

Clients Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

POSSIBLE RISKS, HAZARDS OR COMPLICATIONS

Pain: There can be pain even after the tropical anesthetic has been used, Anesthetics work better on some people than others.

Infections: Very unusual. The area must be kept clean and treated as open wounds. See “Aftercare instruction card” for more details.

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 not symmetrical so adjustments may be needed during the follow up session to correct.

Excessive swelling or bruising: Some people bruise and swell more than others. Ice packs may help, and they will typically disappear within 1-5 days.

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 proceeding.

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 to discuss preventative medication.

Allergic reaction: There is a small possibility of an allergic reaction. You may take a 5–7-day patch test to determine this.

I have been advised of a patch test for the possibility to allergic reaction to pigments and medications. I release Ashlin Reich from any liability should I develop any allergic reactions from the pigment in case of a waiver.

* I hereby authorize Ashlin Reich to perform the elective cosmetic pigmentation procedure, Ombre Powder Brow, understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise during this pmu procedure calling for her judgement for procedures in addition to, or different from those now contemplated, I further request and authorize her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure.

I am not pregnant/nursing

I will follow the aftercare instructions given to me

I understand permanent makeup is a form of tattoo that requires implantation of pigment into the skin

I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur

I am not under the influence of alcohol or drugs or any other substances, legal, or otherwise

I understand it is my responsibility to advise my technician of any concerns I have before the procedure

I understand the result depends on how I follow the aftercare, skin type, lifestyle and touchup appts

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 future application and a touch up session within 90 days

I will tell all skincare professionals or medical personnel about my pmu procedures, especially if I am scheduled for an MRI

I understand some permanent makeup pigment can only be removed with a surgical procedure

I understand there is no refund policy, and no guarantee has been made as a result of this procedure

I accept full responsibility for the decision to have this permanent make up/ Cosmetic Tattoo work done

I certify that I have read and fully understand all the information provided, including the above risks, harzards and complications for permanent cosmetic procedure. As the client, it is your responsibility to inform the technician of all possible concerns before they begin your procedure.

Signature

Date Signed

Date

YESNOOther

Check all that apply:

If you are currently under a physician's care for any condition, please explain:

YES, filing and advertising purposesYES, filing only

I certify that I have read and fully understand the above consent for the Ombre Powder Brow- permanent cosmetic procedure; that the possible complications which may arise or result during or following the procedure are clearly stated and acceptable to me. The service/procedure is performed at my request according to this consent. I have read the pre-procedure form and post procedure guidelines and fully understand and agree to follow all instructions as explained. Client Signature:

Date

PMU CONSENT FORM

INFORMED CONSENT, MEDICAL HISTORY, & RELEASE FORM

POSSIBLE RISKS, HAZARDS OR COMPLICATIONS

MEDICAL HISTORY

PHOTO AND VIDEO CONSENT