To avoid any unforeseen complications, please answer the following questions:

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Yes           No             Are you over the age of 18?

Yes           No             Have you had any aspirin or blood thinning products such as fish oil or Vit E within the last 3 days?

Yes           No             Have you had any mood altering drug in the last 8 hours?

Yes           No             Have you had any alcohol in the last 24 hours?

Yes           No             Do you have hemophilia or any other bleeding disorder?

Yes           No             Do you have a history of being prescribed medications including antibiotics prior to dental or surgical procedures?

Yes           No             Have you had a chemical or laser peel within the last 2 months?

Yes           No             Do you have any problems with healing?

Yes           No             Have you had any previous problems with tattoos, or has your physician advised you not to get a tattoo at this time?

Yes           No             Are you currently undergoing radiation or chemotherapy?

Yes           No             Are you currently using Retin-A, Alpha Hydroxy, glycolic, or any other exfoliating skin care  products?

Yes           No             Are you allergic to any metals?

Yes           No             Have you ever had any permanent make-up procedures done in the past?

Yes           No             Are you taking any anti-inflammatory medications or steroids?

Yes           No             Are you allergic to any topical anesthetics such as Lidocaine, Prilocaine, Benzocaine, Tetracaine, or    Epinephrine?

Yes           No             Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Aquaphor, or family drugs of petroleum?)

Yes           No             Are you pregnant or nursing?

Yes           No             Do you use tobacco?

Yes           No             Do you have any heart conditions?

Yes           No             Are you diabetic?

Yes           No             Do you have any autoimmune disorders?

Yes           No             Do you have any seizure related conditions?

Yes           No             Do you have a tendency to faint or become dizzy?

Yes           No             Are you under treatment for depression?

Yes           No             Do you have botox injections?

Yes           No             Are you on any acne drugs or have taken Accutane in the past 6 months?

Yes           No             Do you take any prescription medications?

Yes           No             Do you intentionally tan in direct sun or in a tanning bed?

Yes           No             Do you personally have a history of cancer?

Yes           No             Do you have a history of strokes?

Yes           No             Are you allergic to hair dyes?

Yes           No             Do you have any type of hepatitis?

Yes           No             Are there any other risks factors for blood borne pathogen exposure that we need to be aware of

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Please initial each statement after you have read and agree with their content

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(s)________.

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Microblading involves the insertion of pigment into the upper-dermal layer of the skin using a blade consisting of a row of tiny needles and is a form of tattooing, though semi-permanent ______.

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Microshading involves the insertion of pigment using a machine into the upper-dermal layer of the skin using  a needle and/or needles and is a form of tattooing, though semi-permanent ______.

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The nature and method of the proposed permanent cosmetic (cosmetic tattoo) procedure has been explained to me by my technician _________.
 

I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness, or other discoloration and swelling ______.

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Topical anesthetics are used to numb the area to be tattooed. I am aware that Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid may be used and I will notify my artist if I have any allergies to these ______.

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Secondary infection in the area of the procedure may occur, however, if properly cared for, is rare ______.

 I understand the permanent cosmetic procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning, or fading of pigments ______.

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Signs and symptoms of infection, include but are not limited to, redness, swelling, tenderness of the procedural site, red streaks going from the procedural site towards the heart, elevated body temperature, or purulent drainage from the procedure site ______.

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If I experience any of these signs or symptoms, I will seek medical care immediately ______.

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I have been informed of the nature, risks, and possible complications and consequences of permanent cosmetics (permanent skin pigmentation/cosmetic tattoo) ______.

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I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin ______.

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I fully understand this is a tattoo process and therefore not an exact science, but an art and acknowledge that no guarantees have been made to me as to the results of the procedure ______.

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I requested the permanent cosmetic procedure(s), and accept the permanence of the procedure, acknowledge the likelihood of fading over time, as well as the possible complications and consequences of said procedure(s) ________.

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I acknowledge 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 ______.

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 I understand that if I have any skin treatments, laser hair removal, plastic surgery, injections, or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I understand that such changes are not the responsibility of my permanent makeup technician. I further understand that such changes in my appearance may not be correctable through further permanent makeup procedures _______.

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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 ______.

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I have disclosed all medications and/or drugs I am taking either prescription or non-prescription and their purpose or indications_______.

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I have informed my permanent cosmetic technician of any medical conditions that may affect the healing of my skin pigmentation _______. 

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I have informed my permanent cosmetic technician of any existing health conditions _______. 
 

I acknowledge that complications are always possible as a result of the permanent cosmetic procedure when post-procedure instructions are not followed ______.

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I acknowledge that hyperpigmentation (darkening of the skin) or hypopigmentation (absence of color in the skin), or scarring is a possibility as a result of my bodies reaction to the skin being broken during the procedure. I acknowledge that my body is unique and that my permanent makeup technician cannot predict how my skin may react as a result of this procedure ______.

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I understand that tattoos may cause MRI (Magnetic Resonance Imaging) artifacts and that there may be a warming and/or tingling sensation in the permanent cosmetic procedural area during the MRI due to the iron oxide (metallic salts) properties of some pigments. I understand that I should advise my physician that I do have permanent cosmetics (a tattoo) in the event of a MRI procedure is prescribed ______.

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I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s). I authorize my permanent cosmetic technician to obtain these pre-and post-procedural photographs and give him/her permission to use said photographs for publication as he/she chooses ______.

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The fee for permanent makeup services has been explained to me and has been agreed upon. I understand the total fee for services rendered is due upon completion of the initial procedure(s) and that future services (apart from the touch up) will have separate fees ______.

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I acknowledge that a touch up/post-evaluation appointment is included in initial fees but may not always been necessary. You must schedule your touch up/post-evaluation appointment within 4-6 weeks after the initial procedure ______.

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It has been explained to me that immediately after the procedure is completed, the color will appear darker than when the procedure heals. It has also been explained that during the healing process, the color will soften ______.

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All color fades, this is a fact that applies to pigments/inks used for cosmetic tattooing. After your initial procedure and any touch up procedure, the healing of your permanent cosmetics is very dependent on daily maintenance of avoiding water, direct sunlight, and any product applied to procedure area. After healing, the appearance of your permanent cosmetics will fade over time but is also dependent on use of strong chemicals applied to the procedure area, applying sunblock daily, and skin type (oily skin retains ink the least over time) ______.

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After your permanent cosmetic procedure, physical activities such as bathing, recreational swimming, gardening, and contact with animals is restricted for the duration of 12 days. This is the duration of healing time for the treated area ______.

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A touch up/color refresher, apart from the initial touch up that is included in initial procedure, will be a charge less than the fee charged for new work if significant work is still visible. If the procedural area is extremely light or not visible, a procedure fee for new work will be charged ______.

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No food, drinks, or making/receiving phone calls are allowed in the procedure area. Email/text is okay as long as it does not interfere with the procedure _____.

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I certify that I have read, understand, 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 permanent cosmetic procedure(s) performed ______.

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Your signature below represents consent to permanent cosmetic services and shall remain in effect during the entire period you remain a client ______.

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I acknowledge by signing this consent form, I have been given the full opportunity to ask any and all questions about permanent makeup procedure(s) and process(es) from my permanent makeup technician.

 

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