Consent For Cosmetic Tattoo Service

I understand that a certain amount of discomfort is associated with this procedure and that swelling and redness may occur. They will dissipate within 24 hours. *

Yes

I understand that any skin treatments i.e. Retin A, Renova, Alpha Hydroxy and Glycolic Acids, laser hair removal, plastic surgery, or other skin altering procedures may result in adverse changes to my permanent makeup. *

Yes

I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. *

Yes

I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue *

Yes

I will tell all skin care professionals or medical personnel about my permanent makeup procedures. *

Yes

I accept the responsibility of explaining to you my desire for specific colors, shape, and position for any procedure done today. *

Yes

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. *

Yes

I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, poor color retention and hyper-pigmentation *

Yes

If I have any signs and symptoms of infections I will seek medical care. These include but are not limited to: redness, swelling, tenderness of the procedure site, red streak going from procedure site towards the heart, elevated temperature, or purulent drainage from the procedure site *

Yes

I understand that after my service, there will be no refunds. No exceptions. *

Yes

I acknowledge that this procedure may alter my appearance and that no representations have been made to me as to remove my permanent makeup. To my knowledge I do not have a physical, mental, medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have permanent makeup. *

Yes

I acknowledge it is not reasonably possible for my technician to determine whether I might have an allergic reaction to the pigments or ointment used in this process. I agree to accept the risk that such reaction is possible. *

Yes

I acknowledge it is not reasonably possible for my technician to determine whether I might have an allergic reaction to the pigments or ointment used in this process. I agree to accept the risk that such reaction is possible. *

Yes

I understand the restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with animals, and the duration of the restrictions *

Yes

*

I certify that I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me.

Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I acknowledge I am age 18 or older *

Yes