PMU Consent Release Form

THE ARTISTRY BEAUTY STUDIO

22672 Lambert Street #604 Lake Forest, CA 92630 PH: 949-424-2104 THEARTISTRYBEAUTYSTUDIO.COM
Informed Consent and Release Agreement

for Permanent Makeup Procedures
Name

First NameLast Name
Appointment Date*

MonthDayYear
Birth Date

MonthDayYear
Phone Number*
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Email*
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Address*

Street Address

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CityState / Province

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Microblading, Ombré/Powder, Lip Blush and Micro-shading are procedures categorized under permanent makeup also known as Micro-pigmentation. The techniques involve the insertion of pigment into the dermal layer of the skin using a device or hand tool. Generally, the results are excellent. However a perfect result is not a realistic expectation. The Micro-pigmentation process is not complete after the initial procedure. Depending on the skin structure, it should be noted during the healing process, change in color intensity and shape is possible and that one or more additional treatments will be required to achieve desired results. This is known as a follow-up appointment required 6-10 weeks post your first appointment to fine tune shape and/or color. Cosmetic Tattooing is an art and NOT science; therefore results vary from client to client and are not guaranteed.

The Artistry, L.L.C and its technicians are obligated to perform procedures in strict compliance with all hygiene and health protection measures. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after each use. Cross contamination guidelines are carefully adhered to at The Artistry.
Health Questionnaire

In order to perform your permanent makeup in a safe manner, please answer the following health questions truthfully
Are you currently nursing or pregnant?*

YesNo
Are you currently on Accutane prescribed by a dermatologist?*

YesNo
Are you currently undergoing Chemotherapy?*

YesNo
Are you diabetic and insulin dependent? If you are insulin dependent you will need to provide a Doctors letter of approval to proceed with the procedure.*

YesNoInsulin Dependent
Do you have Hemophilia or on blood thinner medications?*

YesNo
Are you keloid prone around the face or ears?*

YesNo
Do you have HIV?*

YesNo
Do you have Hepatitus A B or C?*

YesNo
Are you prone to Herpes outbreaks?*

YesNo
Do you have a pacemaker?*

YesNo
Please click all that apply

EczemaRosaceaAutoimmune DisorderEpilepsyCardiovascular problemsConsumed drugs or alcohol in the last 48 hoursUndergo surgery in the last 6 monthsInfections disease, high feverNone
I understand, if I have an autoimmune disorder and/or diabetic, certain medications can affect the outcome of the service and additional touch ups may be needed to achieve desired results.
Please Initial
Please list any allergies to cosmetics, skincare, essential oils, and/or skin sensitivities:
Please list all medications, and/or medical conditions:
Possible Risks, Hazards or Complications
I understand that a certain level of discomfort is associated with this procedure and that swelling, redness and bruising may occur. *
Please initial
Infection: Although rare (less than a 0.25% of the population) there is a risk of infection. The areas treated should be kept clean and only touched with clean washed hands. See "After Care" instructions given *
Please initial
Uneven Pigmentation: Can result from poor healing, infection, bleeding or many other causes including type of the skin, your follow up appointment will likely correct any uneven appearances. *
Please initial
Asymmetry: Every effort will be made to avoid asymmetry but our faces are not symmetrical. Adjustments may be needed during the follow up session to correct unevenness. *
Please initial
Excessive Swelling or Bruising: During and after the procedure, temporary swelling, redness and /or itching may occur. If excessive swelling with unbearable itching and discomfort occurs, call a doctor immediately. *
Please initial
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're allergic please inform me now. *
Please initial
MRI: Pigments used in permanent cosmetic procedures may contain iron oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI technician of any tattoos including permanent makeup.*
Please initial
Allergic Reaction: Although rare, there is a possibility of an allergic reaction to the most advanced and top quality pigments used or other materials used in todays appointment. The client is informed about this and he/she assumes liability. You may take a 5-7 day patch test at least 14 days prior to your appointment to determine this.*

WaiveTake Patch Test (please contact me ASAP)
The Artistry LLC makes no attempt, or claim to practice medicine. Some individuals will have complications related to permanent makeup application. The severity of these complications may vary. By signing below, you agree to understanding the risk related to having the service performed and consent to receiving the service.
Full Name
Contractual Obligations

Please initial each line
I do not currently take nor have I taken Accutane within the last 12 months.*
Please Initial
I am currently NOT using Retin-A, Retinol, Hydroquinone. You must be off these products for at least a month before your procedure.
Please Initial
I understand that Retinol, Retin-A, AHA, BHA, Vitamin C, Alpha Hydroxy and Glycolic Acid and other chemical exfoliant ingredients on the treated areas pre and post appointment will alter color and retention.*
Please Initial
I have not had Botox and/or other cosmetic filler procedures within two weeks of my appointment on or near the area to be treated.*
Please Initial
I have not taken any blood thinning medication 24 hours prior to my appointment, nor have I taken aspirin within 24 hrs. from my appointment. (If you are on Blood Thinning Medications, please contact your doctor for a note of clearance)*
Please Initial
I have not taken any antibiotics within 30 days of my scheduled appointment
Please Initial
I have not been diagnosed with hepatitis or jaundice.
Please Initial
I understand that sun, tanning beds, pools, some skin care products and medications can affect permanent makeup*
Please Initial
The shape is determined according to my face proportions and I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done the day of my appointment.*
Please Initial
I understand that the first seven days color may intensity 40% darker and 10-15% thicker this is part of the process. I will trust the process and refer to the What to Expect information provided to me.*
Please Initial
I understand that the implanted pigment color can alter or fade dependent on skin, skincare products and lifestyle and that one or more additional treatments will be required.*
Please Initial
I acknowledge that Micro-pigmentation involves inherent risks and that there is a possibility of one or more complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper pigmentation. I have informed the artist of any existing allergies medical conditions, and prescribed medications.*
Please Initial
Aftercare instructions have been explained to me and a copy has been given to me to take home and can also be found on our website theartistrybeautystudio.com . I understand that inadequate care in the healing phase of the skin can lead to poor results and The Artistry, L.L.C and the technicians can not be liable for it. If I have questions I will call The Artistry*
Please Initial
I have been quoted the cost of today's appointment, plus $150 for (1) touch up within 6-10 weeks following my first appointment. Additional fees will apply should I NOT adhere to the provided aftercare instructions and less than 50% retention. After 10 weeks, an additional fee will apply for any further touch ups.*
Please Initial
I understand, if I have oily skin and/or have previous cosmetic tattoo, I may need additional touch-ups. If shading is needed, there is an additional $100 fee. I agree and will comply with my technicians professional suggestion
Please Initial
I acknowledge that this is a Low maintenance service and not a No maintenance one and that brow or lip makeup might still be needed.*
Please Initial
RESCHEDULE POLICY: ONE reschedule is permitted with more than 3 days notice of the scheduled appointment date. Additional rescheduling requests and request received within 3 days of the appointment will be charged a Reschedule Fee. The Reschedule Fee is 50% of the total cost of the service, which will be added at checkout on the day of your service.
Please Initial
CANCELLATION POLICY: Notify us as soon as possible if you need to cancel your appointment. Cancelled appointments forfeit deposit/retainer. A new retainer will be required for a new appointment. Note that deposits/retainers are non-refundable and non-transferable.
Please Initial
I acknowledge that NO refunds after any services will be given.*
Please Initial
Consent and Agreement
I acknowledge that I am at least 18 years of age and I certify that I have read or have had someone read the contents of this form to me. I understand the risks and alternatives involved in this procedure as stated. I have had the opportunity to ask questions and all of my questions have been answered.

I realize my body is unique and the artist cannot predict how my skin may react as a result of the procedure. I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as the ability to later change or remove the result.

I understand that future laser treatments or other skin altering services or products may alter or degrade by permanent makeup. I understand that such changes are not the fault of the practitioner. I further understand that such changes may not be correctable through future permanent makeup or removal.

I acknowledge that obtaining permanent makeup services is by my choice alone, and I consent to the application of the procedure and its risks, and to any conduct or actions of the practitioner reasonably necessary to perform the procedure. Tattoos should be considered permanent; that it can only be removed with a surgical or invasive procedure; and that any effective removal may leave permanent scarring and disfigurement.

I understand that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. I further understand that the cosmetic tattooing service is permanent, and no promises have been made in the ability to remove or alter the results.

I acknowledge that I have reviewed and approved the materials given to me and I authorize the Artist of The Artistry, L.L.C to perform Micro-pigmentation on me. I hereby release and forever discharge The Artistry, L.L.C, its technicians and affiliates from all demands, actions or cause of action and any liability arising from the performance including the risks of Micro-pigmentation procedure done today and for all future appointments. It is further acknowledged, that I authorize and grant permission to use before and after photographs for Advertising for The Artistry LLC (i.e. portfolios, brochures, online, social media or print advertisements).

DIGITAL FORM SUBMISSION IS ACCEPTANCE OF TERMS OF SERVICE
(LIP BLUSH CLIENTS ONLY) I understand I must consult a physician prior to my lip tattooing appointment if I've ever had one or more cold sore outbreaks to seek anti-viral medication to prevent a breakout due to the lip tattooing. Further, I understand that if I have a cold sore/HSV-1 outbreak after the service, The Artistry LLC is not liable for any medical bills, scarring, or pigmentation irregularities.
Please Initial
Location of body art

EyebrowsLipsEyebrows and Lips
Artist
Select the Artist performing your treatment
Signature*

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Print Name

First NameLast Name
Date*

MonthDayYear
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THE ARTISTRY BEAUTY STUDIO

Informed Consent and Release Agreement

Health Questionnaire

Possible Risks, Hazards or Complications

Contractual Obligations

Consent and Agreement