The following information is valuable to me, as your technician, in evaluating your healing abilities in respect to your permanent cosmetic services.

Do you presently have or previously had any of the following:
(You MUST Select YES or NO on each item listed)

Consent and Release Agreement for Permanent Cosmetics

This form is designed to give you the information you need to make an informed choice of whether or not to undergo a permanent cosmetic application. If you have any questions, please do not hesitate to ask me.

Although permanent cosmetic tattooing is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of implanting pigment into the dermal layer of skin and is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.

All instruments are new, sealed, sterilized, and disposable. Extreme sanitary measures are used.

Topical anesthetics are used to numb the area of skin to be performed on. Dermacaine, Tetracaine & Benzocaine in a cream form and Lidocaine in gel form are typically used.

Generally, the results are excellent. However, a perfect result is not often a realistic expectation. It is not unusual to expect a small touch-up application after healing has been completed.

The treated area(s) initially may become swollen and/or slightly red. Bruising may occur with eyeliner and full lip procedure. Healing of all procedures will take from I 0-30 days. You will likely experience exfoliating of the skin, redness, itching and possible scabbing. Do not pick or remove this epithelial crust. Doing so will result in loss of pigment. You will use an aftercare product that I provide.

The pigment color initially will be more vibrant compared to the end result. This process is called oxidation. Usually within 5-7 days the color will fade 20-40%, soften and look more natural. Although the pigment is permanent, the color will fade somewhat over time and will likely need to be retouched.

Some possible risks, hazards or complications are:

Pain: There is little to slight pain involved in the procedure once the topicals have been applied and have taken effect. Lip procedures can involve more discomfort.

Infection: Infection is very unusual. The areas treated must be kept clean and you must wash your hands after handling anything, including pets. Do not touch the area with your bare fingers for the first week following the procedure. This may cause contamination. Use only a gauze pad or cotton swabs to cleanse the area. See "After Care" sheet for instructions. 

Uneven Pigmentation: This may result from poor healing, infection, improper care of treated areas, bleeding, etc. Your follow up appointment will determine the reason and resolution. A retouch will be needed in this case.

Poor Contour/ Asymmetry: Every effort will be made to apply the pigment in a fashion that is similar to your usual makeup application contours or the agreed upon shape. If needed, a retouch will give the finishing balance.

Excessive Swelling or Bruising: Some individuals may have more than usual swelling or bruising. This will resolve spontaneously within a day or so. Ice pack applications will help. Some clients have little to no swelling or bruising at all.

Eye Exposure: There is a minuscule risk of eye injury when an eyeliner procedure is performed. To avoid a corneal abrasion, Celluvisc^®, a thick eye drop, is used to protect the eye prior to the procedure to avoid the risk of any topical or pigment damaging or irritating the eye. Refresh Plus^® Eye drops are used to cleanse and flush the eye after the procedure is complete.

Anesthesia: Dermacaine topical cream and Lidocaine with Epinephrine gel are used to numb the skin to be treated. If you are allergic to any of these, please inform me now.

Allergic Reaction: A minute possibility of an allergic reaction may occur; therefore you may take a 5-7 day patch test to determine this.

MRI: Because pigments used in permanent cosmetic procedures contain inert oxides. A low level magnet may be required if you need to be scanned by a MRI machine. You must inform the MRI technician of any tattoos or permanent cosmetics.

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 for a prescription of anti-viral medication to help prevent this from occurring.

The alternative to this procedure is to use cosmetics and not undergo the Permanent Cosmetic procedure.

1. Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession which I will follow to the best of my ability. If l have any questions, I will call you.
2. I understand that a certain amount of discomfort is associated with this procedure and that minor or temporary swelling or redness may occur. 
3. Fever blisters may occur in lip procedures in individuals who have the herpes simplex virus and it is my responsibility to obtain a prescription from my doctor or dentist for an anti-viral medication to help avoid an outbreak.
4. l understand that permanent makeup is a multi-session procedure usually requiring more than one visit to perfect. I am entitled to one (1) free retouch within 45 days of initial visit. All procedures take at least 10-30 days to heal & evaluate. Fading and loss of pigment can occur.
5. l understand that sun, tanning beds, pools, some skin care products, and some medications can affect my permanent makeup. 
6. I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas ever. They will alter the color.
7. I understand that successful lip color saturation cannot be guaranteed due to hidden scar tissue.
8. I have been informed to tell all skin care professionals or medical personnel of any permanent cosmetic procedures I have, especially if I'm scheduled for an MRI.
9. I accept the responsibility for explaining to you my desire for specific color, shape and position for eyebrows, eyeliner, lips, camouflage or areola restoration.
10. 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 color with future applications.
11. I acknowledge that the proposed procedure(s) all involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
12. I have been quoted the cost of today's appointment and procedures which includes one (1) retouch within 45 days and I understand there will be no refunds for this elective procedure(s).
13. I have been shown the sealed, sterilized needle cartridges that will be used for my procedure.

Wake Up Beautiful's insurance company requires "Before and After" photos to be taken and kept on file for reference. Also, they may be used for advertising, example, medical teachings, etc. However, your consent is necessary regarding this.

Consent and release for procedure(s) perfomed:

TERMS AND CONDITIONS

1. Effective Date of this Agreement: This Agreement is effective upon the date that the first medical services is provided and will apply to any and all future similar services provided by the Company to the Customer.
2. Service Pricing Sheet: This Agreement hereby incorporates by reference the contract between Company and Customer for the provision of permanent facial makeup services. The Agreement consists of both the contract and these general terms and conditions.
3. Services Included: Customer and understands and agrees that for the agreed upon fee, Company will perform one permanent facial makeup application procedure. Additionally, the fee includes one (1) post-evaluation appointment. At this post-evaluation appointment, Company and Customer will determine whether a "touch-up" application is required. It is Customer's sole obligation and responsibility to schedule the post-evaluation appointment and Customer must schedule such appointment within forty five {45) days of the initial procedure. customer understands and agrees that he/she shall be charged an additional service fee for any additional "touch-up" application.
4. Payment: Payment is due on or before the date of the initial procedure. Customer understands and agrees that he/she shall be charged an additional fee for any and all future design modification{s) or major color change(s).
5. Quality of Work: Wake Up Beautiful, LLC and Marcy Harris, RN acting on behalf of the Company will perform and complete the work in professional manner consistent with health care provider industry standards.
6. Warranties & Representations: Company and/or Marcy Harris, RN make no representation regarding either Customers appearance as a result of performing any permanent facial makeup procedure or Customer's ability to later change or remove the results of said procedure. Further, Company and/or Marcy Harris, RN make no representation regarding the results of any permanent facial makeup procedure.
7. Limitation on Liability: Company expressly disclaims any liability for the following:
   
   1. Any damages or injuries resulting from the use of any third party products or equipment during or after the procedure;
   2. Any damages or injuries resulting from or in any way related to any of Customer's pre-existing medical conditions;
   3. Any damages or injuries resulting from or in any way related to a failure to disclose or providing Improper information on the "Confidential Medical History" form;
   4. Any discomfort or pain associated with the procedure;
   5. Any of the various side effects that have been explained to me or described in the "Informed Consent Form'
   6. incorporated by reference herein, including but not limited to minor or temporary bleeding, redness or other discoloration and swelling, fever blisters on the lips, fading or loss of pigmentation, or secondary infection in the area where the procedure Is performed;
   7. Any complications that arise from the procedure that is not a result of Company's or Marcy Harris, RN's negligence;
   8. Any hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of skin color) or scarring that occurs as a result of any procedure performed by Company or Marcy Harris, RN. Customer expressly acknowledges and agrees that the Company or Marcy Harris, RN cannot predict how Customer's skin will react to the procedure(s).
   9. Any damages or injuries resulting from Customer's failure to follow the written instructions provided by Company or Marcy Harris, RN regarding proper care of any area where a procedure is performed.
   10. Customer's contraction of Herpes Zoster virus (fever blisters or cold sores) as a result of any permanent facial makeup procedure on Customer's lips.
       
       Customer understands and agrees that the Company expressly disclaims any liability for any harm, costs, or damages that arise or are incurred in such instances as detailed here in Section 7 of this Agreement.
       
       
8. Company Marketing Rights: Customer acknowledges and agrees that Company at its sole discretion may obtain pre­ and post-procedural photographs of the Customer for use in either marketing, publication, or teaching purposes.
9. Entire Agreement; Modification: This Agreement constitutes the entire agreement and understanding by and between the Parties with respect to the services provided under this Agreement and supersedes all prior negotiations, representations, understandings, or agreements. Any modification of this Agreement will require the signed written consent of both parties.
10. Act of God and delays: In the event the completion of inspection and/or work related to this agreement is prevented due to weather, fire, accident, vandalism, natural disaster, theft, labor strikes, material shortage, delay of any governmental agency in issuing any required permit or certificate, or in performing inspections, litigation, or any act of God, such inspection and/or work shall be postponed until such issues are resolved.
11. Governing Law: This Agreement is governed by the laws of the State in which the services or procedures detailed herein are performed, without giving effect to any conflict-of-law principle that would result In the laws of any other jurisdiction governing this Agreement.
12. Venue: Any action, suit, or proceeding arising out of the subject matter of this Agreement shall be litigated in courts located in Clark County, Washington. Each party consents and submits to the jurisdiction of any local, state, or federal court located in the State of washington.
13. Mandatory Arbitration Provision:  Customer expressly acknowledges and agrees that in the event of any dispute between the Parties, that the Parties must resolve any and all such disputes, whether due to malpractice, a breach of this Agreement. or for any other reason, through either voluntary arbitration or Mandatory arbitration through the Clark County Superior Court (LMAR).
14. Attorneys' Fees: In the event of any legal action or proceeding initiated by either party in order to enforce the Agreement or any provision hereof, or in connection with any alleged dispute, breach, default, interpretation, or misrepresentation in connection with any provision contained herein, the non-prevailing party wlll pay the prevailing party's reasonable attorneys' fees and costs incurred in connection with such action or proceeding. These costs include, but are not limited to, the costs of pursuing or defending any legal action which may include an appeal, discovery, or negotiation and preparation of settlement arrangements.
15. Severability: If any provision of this Agreement is held to be invalid or unenforceable in whole or in part, such invalidity or unenforceability will attach only to such provision or part thereof and the remaining part of such provision and all other provisions hereof will continue in full force and effect.
16. lnterpretation: Customer will not interpret this Agreement to construe its terms against Wake Up Beautiful, LLC.
17. Binding Nature of Agreement: The Parties expressly acknowledge and agree that each and every Term and Condition of this Agreement, including the obligation to arbitrate any dispute, is binding on each party, its successors, heirs, assigns and family members.

Acceptance of the contract constitutes agreement to these general terms and conditions and acknowledgement that you have received separate copies of both the "Permanent Cosmetics care and Information" and "General care (Pre- and Post Procedural) Instructions" guidelines.