CONSENT FORM

YOU MUST BE 21 YEARS OLD OR OLDER TO DO THE PROCEDURE

FIRST NAME *

LAST NAME *

PHONE NUMBER *

CONSENT AND RELEASE AGREEMENT

REVIEW THE FOLLOWING STATEMENTS AND INITIAL TO VERIFY YOUR UNDERSTANDING

I have been advised that the pigment is semi-permanent and will fade over time and understand that touchups may be needed. *

YES

NO

I have been quoted for the cost of today’s procedure and informed of the touchup price. I understand that the initial touchup is to be performed within 60 days in order to be booked at the touchup rate. If I book anytime after that, I may be subjected to pay full-price for the service requested. *

YES

NO

I understand that anesthetics have varied effectiveness on each person and that discomfort or pain may persist even after a topical anesthetic has been applied. *

YES

NO

I understand that swelling, redness, and bruising may occur from this procedure. *

YES

NO

I understand the risks associated with the procedure(s) and that there may be poor color retention. *

YES

NO

I have been provided aftercare instructions, which I will follow to the best of my ability. If any questions or concerns arise, I will notify my cosmetic professional. *

YES

NO

I accept the responsibility to decide and explain my desired colors, shapes, and positions for any procedures performed as agreed upon during consultation. *

YES

NO

I understand that products containing Retin A, alpha hydroxy, and glycolic acids shall not be used on the treated areas because they may alter the color or cause the pigment to exfoliate prematurely. *

YES

NO

I will tell any skincare professionals or medical personnel about my semi-permanent makeup procedure(s), especially if I am to receive an MRI. I understand that this is because the pigment used may contain compounds that require a magnet. *

YES

NO

I understand that exposure to the sun, tanning beds, pools, some skin care products and makeup, sweat, and medications can affect my semi-permanent makeup. *

YES

NO

I acknowledge that faces are not necessarily symmetrical and that while every effort will be made to avoid asymmetry, adjustments may be required during the touch-up session to correct any unevenness. *

YES

NO

I understand that color saturation is not guaranteed and may be negatively affected by hidden scar tissue. I also acknowledge that pigment color may change or fade over time due to circumstances beyond my cosmetic professional’s control. I have been informed that some reasons for this include poor healing, improper aftercare, infection, bleeding, and other causes. I understand that the initial touchup session is meant to correct any fading, unforeseen changes, or uneven appearance. *

YES

NO

I understand that infection is rare, but may occur and is serious. I acknowledge that I am to keep the treated areas clean. i will refer to and follow the provided aftercare instructions to be as preventative as possible. *

YES

NO

I understand that I may have an allergic reaction to products, tools, or materials used. *

YES

NO

Please list all known allergies

RISK ACKNOWLEDGEMENT

This document will describe the possibilities and side effects associated with semi-permanent cosmetic
tattoos. Please review the following information and sign to verify your understanding.

DISCOMFORT/PAIN: There is associated pain and discomfort that may persist even after topical
anesthetic has been applied. Effectiveness of anesthetics and pain tolerance may vary depending on
each individual.

INFECTION: Infection is rare, but may occur and is serious. I acknowledge that I am to keep the treated
areas clean. I will refer to and follow the provided aftercare instructions to be as preventative as
possible.

APPEARANCE: Fading, patchiness, unevenness, and lack of retention may occur. Various factors
contribute to these complications such as poor healing, improper aftercare, infection, bleeding, and
other causes. Other products and exposures may also alter the final result.

SWELLING/BRUISING: Some individuals may bruise or swell following the procedure.

ASYMMETRY: Faces are not necessarily symmetrical, so while every effort will be made to avoid
asymmetry, adjustments may be required during the touchup session to correct any unevenness.

ALLERGIC REACTIONS: Some individuals may have an allergic reaction to numbing agents or pigments
used. A patch test may help avoid adverse reactions but cannot guarantee against them. It is the
client’s responsibility to inform their cosmetic professional of any known allergic reactions or
sensitivities.

MRI: Clients are responsible for informing medical professionals about any semi-permanent makeup
procedures received, especially if they are to receive an MRI. This is because the pigment used may
contain compounds that require a magnet.

*

YES, I understand

NO, I don't understand

* Notice 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.

PHOTO AND VIDEO CONSENT

This document is to request your permission to take photos of you and the treated areas before and/or
after the procedure(s). These photos may be used for advertising and marketing, portfolios, training,
and other use. Your consent is necessary in order to proceed with using said photos.

Please select one of the following options regarding your consent for use of photos from your procedure: *

YES, you may use photos of me and my treated areas

NO, you may NOT use photos of me nor my treated areas

SIGNATURE *

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