Lip Blush Tattoo Consent Form
Your Name
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First Name
Last Name
Are you over 18 years old? An ID will be required the day of your appointment.
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Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name & Phone Number
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Pre-Procedure Questionnaire
Do you have an existing lip blush tattoo?
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Yes
No
Are you taking any blood thinning medicine?
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Yes
No
Are you pregnant or nursing?
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Yes
No
Please include any notable conditions about your medical history (Diabetes, CardiovascularDiseases, Hepatitis, Hemophilia, HIV-AIDS, Epilepsy, Blood-related disease, Seizures, Fainting, etc)
*
Do you have any skin conditions? Please note any skin conditions, such as but not limited to: acne, scarring (Keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed:
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Do you have a history of cold sores (HSV-1)?
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Acknowledgment and Waiver
I acknowledge by signing this agreement that I have been given the full opportunity to ask any questions that I might have about the obtaining of lip blush, and that all of my questions have been answered to my satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below, and I agree as follows: (if any of these are not checked, please confirm with your artist, as you might not be able to proceed with the tattoo):
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I voluntarily consent to receive a lip blush cosmetic tattoo procedure, which involves implanting pigment into the skin using a tattooing device. I understand that this is a form of body art and that results vary by individual.
I understand that lip blush tattooing may trigger a cold sore (herpes simplex virus) outbreak, even if I have never had one before. If I have a history of cold sores or believe I may be susceptible, I acknowledge that it is my responsibility to consult with a licensed healthcare provider before my appointment to determine whether preventative antiviral medication may be appropriate. I understand that some individuals choose to take over-the-counter supplements such as L-lysine before and after cosmetic tattoo procedures. This is voluntary, not medical advice, and should be discussed with a healthcare provider. I understand that no preventative measure can guarantee that a cold sore outbreak will not occur.
I acknowledge and accept the possible risks associated with lip blush, including but not limited to: Swelling, redness, tenderness, infection, allergic reaction, uneven color, retention, fading or color changes, scarring (rare), and cold sore outbreak. I understand that results are not guaranteed and that pigment retention varies.
I confirm that I have received and understand the pre-care and post-care instructions and agree to follow them. Failure to do so may affect healing and final results. I understand that arriving with an active cold sore or skin infection will require my appointment to be rescheduled.
I understand that lip blush typically requires a healing period and may require a touch-up for optimal results. Healing timelines and final color outcomes vary.
I understand that the artist is not a medical professional, does not diagnose medical conditions, and does not prescribe medications. No medical advice has been given to me, and any information provided is for educational purposes only.
I am the person on the legal ID presented as proof that I am at least 18 years of age. I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representative and employees of the tattoo shop reasonably necessary to perform the tattoo procedure.
I acknowledge the information I provided in the medical questionnaire is complete and true to the best of my knowledge.
I understand there is a possibility of getting an infection as a result of receiving body art. I will seek professional medical attention if signs and symptoms of infection occur.
I acknowledge that Diana Pantoja does not offer refunds.
I acknowledge that it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
I understand that I need to take care of the tattoo by following the instructions given to me by the artist.
I indemnify and hold harmless Diana Pantoja against any claims, expenses, damages, and liabilities.
I give permission to use of my photos for the purpose of marketing. My pictures may appear in print or online.
If I have any condition that might affect the healing of this tattoo, I will advise my tattoo artist before the procedure.
I am not under the influence of alcohol or drugs.
Client Signature
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Signed Date
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Month
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Day
Year
Date
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