Consent To Application Of Permanent Makeup Procedure
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1CONSENT TO APPLICATION OF
PERMANENT MAKEUP PROCEDURE
NAME
DATE
DOB
ADDRESS
CITY
STATE
ZIP
HOME/CELL PH.
WORK PH.
EMAIL:
I,
am over the age of 18, am not under the influence of drugs or alcohol, am
not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general
nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.
PROCEDURE(s):
NO. OF VISITS REQUIRED:
COST OF PROCEDURE(s):
I have been informed of the nature, risks, and possible complications and consequences of permanent skin
pigmentation. I understand the permanent skin pigmentation procedure carries with it known and
unknown complications and consequences associated with this type of cosmetic procedure, including but
not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments.
Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon
after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due
to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact
science, but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence
of the procedure as well as the possible complications and consequences of the said procedure(s). X
There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not
ensure a client will not have an allergic reaction.
I consent
(initial) or waive
(initial)
the
patch test. If waived, I release the technician from liability if I develop an allergic reaction to the
pigment.
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering
procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these
potential adverse changes may not be correctable. X
I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I
understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any
medication for depression or any other mood altering prescription, I will advise my technician. If I have
ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating
any permanent cosmetic procedure around my lips. X
I understand that the taking of before and after photographs of the said procedure(s) are a condition of
such procedure(s). I certify I have read and initialed the above paragraphs and have had explained to my
understanding this consent and procedure permit. I accept full responsibility for the decision to have this
cosmetic tattoo work done.
CLIENT:
DATE
TECHNICIAN
DATE
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