Consent page 1

Micropigmentation/Permanent Makeup Informed Consent

Name

Date Of Birth

Date

Address

City

State

Zip

Cell

Email Address

example@example.com

How did you hear about Permanent Makeup By

How did you hear about Permanent Makeup By Lauren

The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur. as a client have requested that you described the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. You have described the recommended procedure to be used as Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin. Micro Pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage. I voluntarily request as my Intradermal cosmetic technician, Lauren Wade to perform on my body the following procedure:

List Procedures Below (i.e brows, lips eyeliner, scalp etc)

By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:

Please initial the line next to the number after you clearly understand each statement.

Signature I have informed the practitioner of any and all of my known allergies. acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.
Signature l acknowledge that complications as a result of semi-permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.
Signature I realize that my body is unique and neither Lauren Wade nor its employees or contractors can predict how my skin may react as a result of the procedure.
Signature I have previously had micropigmentation performed by someone other than Lauren Wade on the same area (brows, Lips, liner, ETC) that I am asking Permanent Makeup By Lauren to work on today - Yes NO
IF YES, Signature I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Permanent Makeup By Lauren has no control. I understand that additional appointments after the initial appointments may be required, and will be billed at Permanent Makeup By Lauren standard rates. I understand that Permanent Makeup By Lauren cannot predict the results in advance and cannot guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold Permanent Makeup By Lauren harmless from same.
Signature I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.
Signature I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my semi-permanent makeup, and that I must inform any future service provider that I have had micropigmentation applied. I understand and accept that such changes are not the fault of Permanent Makeup By Lauren or its employees or contractors.
Signature I further understand that such changes or degradation in my appearance may not be correctable through further semi-permanent makeup procedures.
Signature I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.
Signature I acknowledge that obtaining the semi-permanent makeup is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of Permanent Makeup By Lauren and its employees and contractors reasonably necessary to perform the procedure.
Signature I understand that I will have the opportunity to approve the design and color of the semi-permanent makeup to be applied, and I accept responsibility for the same.
Signature I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of Permanent Makeup By Lauren.
(optional/requested) Signature I DO I DO NOT consent to Permanent Makeup By Lauren using "before & after" photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting Permanent Makeup By Lauren, which will then discontinue use of said photo(s).
Signature I have been given the full opportunity to ask any and all questions which I might have about obtaining semi-permanent cosmetic procedures from a micropigmentation specialist at Permanent Makeup By Lauren, and that all of my questions have been answered to my full and total satisfaction. I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure.
Signature I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Lauren Wade as well as a seek out treatment by a medical professional.
Signature I have received a copy of post procedure instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its contents.
Signature I certify this form has been fully explained to me and I have read it or it has been read to me. I understand its contents.
If you have previously had micropigmentation performed by Permanent Makeup By Lauren, has your medical history changed since you last filled out your medical profile form?

   YES    NO
If YES, please specify.   changes to medical history since last visit? We

I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself.

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