CONSENT TO IMPLANTATION OF PIGMENT PROCEDURE

To be filled out the day of the procedure

 

 

CLIENT NAME_________________________________________DOB____________________ID/DL NO. ________________________

PHONE NUMBER.   _______________________________ DATE:_______________ Refered By________________________________ 

Procedure requested, Please Initial:

Microblading Brows__________ Powder Brows_________ Compact Brows________ Combo Microblading/Powder Brows__________

Eyeliner: Top Lash Line___________Bottom Lash Line________ Lip Blush_____________ Lip Liner _____________

You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is not meant to frighten you. It is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure.

 

Please read the statements below, putting your Initials before each one to indicate:

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a Permanent Makeup and that all of my questions have been answered to my full satisfaction.  I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows: 

 

 

Do you have the area previously tattooed?                   

 

No                                

 

Yes 

(if yes, you may need some correction, camouflage or an extra touch up for an Extra charge)             

 

Initials

  • That no warranty or guarantee has been made to me as a result of this permanent makeup/camouflage/correction procedure and the final result cannot be guaranteed. 

 

  • That such procedure is a process, often requiring multiple applications of color to achieve desirable results and 100% success cannot be guaranteed.

 

  • I have received, reviewed and understand the written and verbal post procedural instructions as given to me and agree to follow them.

 

  • I realize that there is potential for discomfort during the procedure and during the healing process.

 

  • There is a possibility of bleeding, swelling, or allergic reactions to the procedure.

 

  • That permanent makeup is considered permanent; however, it fades with time.

 

  • That permanent makeup can only be removed with surgical procedure, and that any effective removal may leave permanent scarring or disfigurement.

 

  • That Enhancink Skin Care will not, under any circumstances, perform any permanent makeup procedures on me if I am known to have any allergies to the product used.

 

  • If I have any condition that might affect the healing of this Permanent Makeup, I will advise my technician. 

 

  •  I am not pregnant or nursing.  

 

  • I am not under the influence of alcohol or drugs.   

 

  • I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be treated that may interfere with such treatment.  If I have any type of infection or rash anywhereon my body, I will advise my technician.

 

  • I acknowledge it is not reasonably possible for the representatives and employees of Enhancink Skin Care to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.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. If waived, I release the technician from liability if I develop an allergic reaction to the pigment.

 

 

  • I acknowledge that infection is always possible as a result of the obtaining of a permanent makeup, particularly in the event that I do not take proper care of my procedure.  I have received aftercare instructions and I agree to follow them while my procedure is healing.  I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.    

 

  • I realize that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body.  I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.

 

  • 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 procedure. 

 

  • I acknowledge that this procedure is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my permanent makeup.  

 

  • To my knowledge, I do not have a physical, mental or medical impairment or disability, which might affect my well being as a direct or indirect result of my decision to have a permanent makeup.  

 

  • I understand that I must inform my technician of all medications being taken by me, even though I have written it on the General Medical History and Confidential Medical History forms. For example, pain control medication such as aspirin may cause the blood to thin, and excessive bleeding may occur. 

 

  • I understand there will be no money back under any circumstance. I understand that there is a no refund policy.

 

  • I understand the cost of touch up’s are not included in the procedure, and the cost of touch ups differs as time lapses from the original date procedure was done

 

  • I agree to accompany my permanent makeup cosmetic practitioner to the emergency room in the event they were to be accidentally stuck with my needle and agree to take a blood test for their safety, as well as disclose all test results to my practitioner.

 

  • I acknowledge I am over the age of 18 and that I have truthfully represented to my technician that the obtaining of a permanent makeup is by my choice alone.  I consent to the application of the permanent makeup and to any actions or conduct of the representatives and employees of the permanent makeup facility reasonably necessary to perform the permanent makeup procedure.

 

  • I understand 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. 

 

  •  I understand before and after photographs of procedures may be taken and the rights to all photographs taken belong to Enhancink skin Care, and therefore may be used in anyway Enhancink Skin Care chooses to do.

 

I DOAuthorize Enhancink to Share my pictures on the media_______________Yes

 

OR

 

I DO NOTwish Enhancink Skin Care to share my pictures on the media.

Only If you DO NOTwant your pictures to be shared please initial here ______________NO

 

 

  • ACCEPTANCE: I have thoroughly read and understand this document. The risks involved with my procedure(s) have also been verbally explained to me. I fully understand the written and verbal post care instructions. I certify that all of my questions have been answered and I accept full responsibility for any complications that may arise during or following the procedure(s) to be performed at my request.

 

 

 

 

CLIENT SIGNATURE:                                                                                                                 DATE                                            

TECHNICIAN SIGNATURE:                                                                                                       DATE_______________________