• Cosmetic Tattoo Consent Form

  • Format: (000) 000-0000.
  • Date of your appointment *
     - -
  • Which procedure(s) are you getting today:

  • Clinical Outcome of Procedure(s):

    The result of your procedure is determined in part by nature of the pathology of your skin type, but not limited to the following factors:

    •  Medication you are currently taking
    •  Blood type, lifestyle, existing hair, and bone structure
    • Skin characteristics: dryness, oiliness, thickness, sun-damaged, color, chemically   damaged, etc.
    • Natural skin undertones mixing with pigment color
    • Personal pH balance of the skin, tanning booths, fruit acids, AHA’s and Retin A use
    • Alcohol intake, smoking, sun exposure, improper skin care
    • Following pre-care and aftercare instructions
    • Existing tattoo that was done by another artist
    • In some cases, the factors can or may interfere with acceptance and fading of color pigment

    By signing this, I understand that my results are not guaranteed to be 100% success due to the clinical outcome of the procedures listed above. I accept full responsibility for any complications that may arise or result during or after the following cosmetic procedure(s) to be performed at my request. I do not hold my technician, Luna Moon Ink LLC, and all members and employees of Kimm Artistry LLC reliable for any complications that may arise during or after the following cosmetic procedure(s) to be performed at my request. I certify that the information in the above questionnaire is accurate, that it has been explained to me, and my all my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request.

  • Date of appointment*
     - -

  • INFORMED CONSENT

    Initial Below

  • ACCEPTANCE:

    By signing below, I have read and understood these risks listed above and they have been explained to me. I DID NOT JUST SIGN THIS DOCUMENT.

    I certify that the information in the above questionnaire is accurate, that it has been explained to me, and my all my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request.

  • Date of appointment*
     - -

  • POLICIES, TERMS & CONDITIONS

    The procedure will not start until you have agreed on the shape. Please make sure you are completely satisfied before the procedure begins and before leaving the studio. We will constantly ask for your approval of the shape and adjust the shaping at your request before tattooing.

     

    Everyone is different and can respond to topical numbing differently. How much you bleed will affect the outcome of your results and therefore require additional appointments to achieve the desired results. Cosmetic tattoos are a 2-step process.

     

    Photos and videos taken during the entirety of your cosmetic procedure will belong to Luna Moon LLC. They may be posted on @LunaMoon_Ink on Instagram, our website, or any social platforms used by Luna Moon Ink LLC. Photos and videos will also be used in our training courses and training manual. 

     

    All services require a non-refundable deposit fee. The fee is to secure the appointment time/day. Cancellations for any reason will result in forfeiting your deposit.

     

    72-hour notice is required for rescheduling. Failure to notify us within 72-hour prior to your appointment will result in the loss of your appointment and your deposit will be forfeited. You will be charged another deposit for the future appointment. Deposit is transferable for one time only if the rescheduling was done 72 hours prior to the original appointment time. 

     

    No shows will not be able to book another future appointment.

     

    Late policy: You have a 15-minute grace period before your appointment gets cancelled. Please let us know if you are running late.

     

    No additional guests are allowed. Children and pets are also not allowed.

     

    All services are NON-REFUNDABLE under any circumstances. If there are any issues, we will try our best to correct them. Everyone’s skin takes in permanent makeup differently, therefore, we cannot guarantee a 100% successful result to our clients. There are also no refunds as we have carried out the service.

     

    Results may vary due to the individuals skin type, blood type, lifestyle. existing hair, bone structure, use of medications, pre-care, and aftercare.

     

    A second session is recommended 6 weeks from the first session to ensure the desired results. Cosmetic tattooing is a 2-step process. Second session pricing will be determined on the timeframe you return. It is your responsibility to book this with within the suggested timeframe. On a rare occasion, a client may need a third or fourth session due to having a skin type that is more resistant. The client will be charged accordingly.

     

    The touch up session is not to change the shape or color of the initial appointment. If you would like to change the shape of your enhancement during your touch up appointment, you will be charged accordingly for the services.

     

    Contraindications: Permanent cosmetic procedures are not recommended if any of the contraindications listed below apply to you. Please consult with your physician prior to booking.

    Under 18 years of age
    Pregnant and/or breastfeeding
    History of allergy to makeup and pigmentation
    Skin disorders such as eczema or psoriasis in the area to be treated (acne, sunburn, rashes, etc.)
    Had Botox/Injections in the past 2 months in the area to be treated
    Active skin cancer in treated area
    History of post inflammatory hyperpigmentation/keloid scarring
    Viral infections/diseases: Hepatitis or HIV
    Diabetes
    Prescribed blood thinning medications
    Hemophiliac
    Healing disorders
    On Accutane, antasure, or steroids
    Undergoing chemotherapy (Must be no less than 7 months ago from date of procedure)
    Epilepsy, seizures
    Surgeries including blepharoplasty and or brow lift in the last 6 months

    EYELINER CLIENTS: Keloids, spider veins, fresh scars, sty/blisters on the eyes, dry flakey eyes, allergies


    *We reserve the right to refuse service to anyone, at any time, for any given reason.

    *Prices are subject to change at any time WITHOUT NOTICE.

     

    By signing below, I have read and understand everything that was provided in this packet, and they have been explained to me. I DID NOT JUST SIGN THIS DOCUMENT. I accept full responsibility for any complication that may arise or result during or after the following cosmetic procedure(s) to be performed at my request.

     

    By signing, I have read and agree to the policy above.

  • Date of appointment*
     - -

  • MEDICAL INFORMATION

    Please check Yes or No
  • Do you have a history of herpes infection at the proposed site? (I.E., cold sore.)*
  • Are you pregnant or nursing?*
  • Do you have epilepsy, hemophilia, or other bleeding disorders?*
  • Are you on any blood thinning medication(s)?*
  • Do you take aspirin?*
  • Do you smoke?*
  • Do you drink alcohol?*
  • Do you have cardiac valve disease?*
  • Do you suffer from any heart conditions?*
  • Prior to dental or surgical procedures, do you receive antibiotic therapy?*
  • Are you on steroids or anti-inflammatory medications?*
  • Do you suffer from Hepatitis, other risk factors for blood borne pathogen exposure, or any communicable disease?*
  • Do you have diabetes and use insulin?*
  • Do you suffer from a medical or skin condition such as keloids or hypertrophic scarring, psoriasis (at the procedure site) or any open wounds or lesions?*
  • Do you bruise, swell, or bleed easily?*
  • Do you use Retin-A, glycolic acid, vitamin C, or other exfoliates?*
  • Are you currently on steroids, Accutane, antasure?*
  • Do you have an autoimmune disorder?*
  • Do you have a history of medication use or currently using any medications?*
  • Do you have Trichotillomania? (pulling of hair, eyebrows, or lashes)*
  • Do you have pre-existing nerve damage in the area that I will be working on?*
  • Do you have tattoos?*
  • Are any of the colors in your tattoo(s) sensitive to sun or rise in the sun?*
  • Are you currently tanned in the area(s) to be treated?*
  • Do you tint your eyebrows?*
  • Have you had Botox in the area to be treated?*
  • Have you ever had an allergic reaction to a topical antibiotic?*
  • Have you ever had an allergic reaction to lidocaine or any topical anesthetic?*
  • Do you have reactions to cosmetics, latex, or seasonal Hay Fever?*
  • Have you had a chemical peel?*
  • Do you spend a lot of time in the sun and/or in a chlorinated pool?*
  • Do you use sunscreen regularly?*
  • Have you had any facial cosmetic surgery?*
  • Do you plan on getting facial cosmetic surgery in the future?*
  • Have you had laser treatments?*
  • Are you allergic to any Cetaphil products?*
  • Have you had an allergic reaction to any topical ointments?*

  • I hereby certify that, to the best of my knowledge, all statements contained here are true.

  • Date of appointment*
     - -

  • GENERAL AFTER CARE

  • Aftercare Instructions for aftercare for the following 7-14 days. ​

    IMMEDIATELY AFTER: Blot the treated area with a clean cotton pad to remove excess lymph fluid. Do this every 30 minutes for the next 2 hours (4 times total). Make sure to clean hands prior.

    ​

    24 hours after your appointment, wash the treated area with the gentle skin cleanser. Use a pea sized amount, foam up the cleanser in your fingers. Make sure to use extremely light pressure. Wash the soap off with cool water, pat dry with a disposable paper towel, and use a clean q-tip to apply a thin layer (rice grain size) of ointment. Repeat once a day until the area have completely healed. (Do not apply a thick layer of ointment, it will block the oxygen flow and delay your healing.)

    ​

    It is normal that the treated area start to scab and peel off. During this process they will become very itchy. DO NOT SCRATCH, RUB, PICK, OR PEEL OFF THE SCABS. Allow them to fall off naturally. Failure to do so will result in loss of pigmentation in the area.

    ​

    Clean hands prior to touching the treated area. They may have bacteria on them and create an infection. Use a clean cotton tip applicator when applying ointment. DO NOT double dip a used cotton tip into the jar.


    No makeup on or near the procedure area. No tinting of lashes or brows. No heavy sweating and direct sun exposure. Avoid sun, saunas, and swimming (including chlorinated pools or Jacuzzis, the ocean, or recreational bodies of water), contact with animals or gardening for 7 to 10 days after the procedure(s). 


    Do not rub or traumatize the procedure area while it is healing (pigment might be removed along with the crusting tissue).


    Use a broad-spectrum sunscreen after area has healed to slow fading.


    Avoid AHAs, Retin A, gycolic acid, or lactic acid on or near pigmented areas (they will fade the color).


    Avoid products containing Aloe Vera or vitamin E during the healing process. 


    Do not donate blood for one year after the procedure, per the Red Cross. 


    Follow up appointments are done between 6-12 weeks after the initial procedure. PMU is a 2-step procedure that requires a second session to enhance the brows. 


    If you experience excessive itching, swelling, blistering, or other complications post procedure, stop using the aftercare product and call your technician immediately. You may be allergic to the aftercare product


    FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN PIGMENT LOSS.

     

    WHEN TO SEEK MEDICAL ATTENTION - INFECTION

    Signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature em or purulent drainage from the procedure site.
    If you are experiencing any of the symptoms above, please contact your medical physician. 

    ___________________________________________________________

    Aftercare instructions are also available on our Instagram: @LunaMoon_Ink

    If you have any other questions or concerns, please contact us.

    Phone: (510)-322-1802  [text only]

    Email: LunaMoonInk15@gmail.com

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