Micropigmentation Informed Consent

Micropigmentation Informed Consent
Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Health Contraindications - Nano Hairstrokes Brow

if you have any of the following, you may not be a good candidate for this treatment :
-Under 18 years old
-Pregnant or Breastfeeding
-Allergies to topical anesthetics or pigment
-Keloid scarring
-Eczema, Psoriasis, Rashes, Severe Acne on the Treatment Area
-If you have a transmittable blood disease such as HIV or hepatitis
-Accutane in the past year
-Viral infections and/ or diseases
-Chemical peel within the last few weeks
-Medications, treatments, or illness that compromises the immune system
-Diabetes, Chemotherapy and any other Medical conditions consult your doctor (must provide doctor's note)
-Botox near brows within 4 weeks
I have thoroughly read the Health Contraindications list, disclaimer and affirm that nothing applies to me
The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained tome as having the usual risks inherent in the procedure and the possibility of complications during and following itsperformance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fever blisters may occur on the lips following lip procedures in individuals prone tothis problem. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur.
I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.
I acknowledge that complications as a result of semi-permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.
I realize that my body is unique and neither SMILELASH & BROW nor its employees or contractors can predict how my skin may react as a result of the procedure.
I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.
I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my semi-permanent makeup, and that I must inform any future service provider that I have had micropigmentation applied. I understand and accept that such changes are not the fault of SMILELASH & BROW or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further semi-permanent makeup procedures.
I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.
I acknowledge that obtaining the semi-permanent makeup is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of SMILELASH & BROW and its employees and contractors reasonably necessary to perform the procedure.
I understand that I will have the opportunity, within the time constraints of my appointment, to approve the design and color of the semi-permanent makeup to be applied, and I accept responsibility for same.
I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of SMILELASH & BROW and its’ associates.
I consent to SMILELASH & BROW using “before & after” photos of me for marketing purposes to display its capabilities and results. However, if I wish to withdraw my consent, I must notify SMILELASH & BROW.
I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent cosmetic procedures from a micropigmentation specialist at SMILELASH & BROW, and that all of my questions have been answered to my full and total satisfaction.
I have previously had micropigmentation performed by someone other than an associate of SMILELASH & BROW on the same area (brows, lips, etc.).*

YesNo
IF YES, I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which SMILELASH & BROW or its’ associates has no control. I understand that additional appointments after the initial and follow-up appointments may be required, and will be billed at SMILELASH & BROW ’s standard rates. I understand that SMILELASH & BROW cannot predict the results in advance and cannot guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and will not hold SMILELASH & BROW or its’ associates liable.
I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. I hereby release and forever discharge and hold harmless SMILELASH & BROW and its owners, managers, employees and affiliates from any and all claims, damages or legal actions arising from or connected in any way with my micropigmentation, or the procedure and conduct used in my performing my tattoo, to the fullest extent allowed by the law.
Signature*

Powered by Jotform SignClear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Micropigmentation Informed Consent

Health Contraindications - Nano Hairstrokes Brow