Informed Consent Form

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Let us do this part

Today's Date:

Sat Apr 20 2024 01:03

Practitioner:*

Artist signature:*

Informed Consent

Please read and answer

Pigment Test (I don't want one)

I understand a pigment (skin ) test of the pigment to be used is offered upon request and the test result is not viewed by a medical professional unless I make arrangements to have this done myself. A nonreactive skin test does not prevent an allergic reaction occurring at a future point in time.

I DECLINE THE SKIN TEST

Pigment Test (I want one)

Health Issues*

I have informed my permanent cosmetic technician of any existing health problems including exposure to Covid-19

Complications*

I acknowledge that complications are always possible as a result of the permanent cosmetic procedure, particularly in the event my post-procedural instructions are not followed.

Skin Pigmentation*

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

After Care*

I acknowledge the receipt of written instructions advising me of the proper care of my procedures and I recognise the absolute necessity for following these instructions. THIS IS IMPORTANT FOR THE BEST HEALED RESULTS

Permanence*

I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results

Future Treatments Outside of this clinic*

I understand that future laser treatments or other skin altering procedures, such as plastic surgery, implants, and injections may alter and degrad my permanent makeup. I further 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 though further permanent makeup procedures.

Guarantees*

I am aware that cosmetic tattooing is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the procedure.

Photographs full face or procedure only*

I authorise my permanent cosmetic technician to obtain pre-procedural and post-procedural photographs, and give her permission to use such photographs for publication and/or for teaching purposes, as she chooses.

Option 1. Full face
Option 2. Procedure only

Herpes Virus*

I am aware that the Herpes Simplex Virus type I (HSV-1) (fever blisters or cold sores) may occur as a result of a lip procedure due to trauma to the lip tissue. The anticipation of an outbreak may be pretreated with antiviral medication, available by prescription from your physician.

MRI*

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. It is understood that I should advise my physician that I do have permanent cosmetics (a tattoo) in the event an MRI procedure is prescribed.

Fees*

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 there will be separate fees for any future modification of the design(s) or major colour change(s).

No refund Policy*

Due to the fact that my approval is obtained prior to final selection of colour to be implanted and design application(s) to be applied, my technician employs a no refund policy.

Further appointments*

For some skin types and procedures, permanent cosmetics may be a multi session process. In addition to your inital application you are entitles to a post-evaluation appointment. At the post-evaluation appointment it will be determined if a touch up to the initial application is required. You must schedule your post-evaluation appointment within 45 days after the initial procedure.

Fading of Pigment*

All colour fades - this is a fact that also applies to pigment/inks used for cosmetic tattooing. After your procedure(s) has been performed and any subsequent work performed at the post-procedure appointment, the pristine appearance of your permanent cosmetics is very dependent on daily maintenance of avoiding direct sunlight (intentional tanning), avoiding strong chemicals applied to the procedural area, and applying sun block daily (frequently if in a a situation where activities take you in the sun). Colour refreshers will be needed at some point in the future. The time frame for that need cannot be predcicted, as this aspect of permanent cosmetics is very client specific. If the procedural area is dense enough (can be easily seen), that one application of pigment/ink will bring the colour back to its original appearnace, a colour refresher fee will be charged that represents a lower charge than the fee charged for new work. If the procedural area is extremely light and only represents a weak version of the original procedure, or if it is not visible, a procedure fee for new work in effect at the appointment when the colour is reinstated will be charged.

Guarantees & Warranties*

I have read and understand the contents of the paragraphs above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realised from, or consequences of, the aforementioned procedure(s).

Your signature*

Your signature below represents consent for permanent cosmetic services and shall remain in effect during the entire period you remain a client of Jeni Hart (technician at Brows &
Beyond)

The Client*

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.

The Technician*

I personally reviewed the above information with my client, or the clients representative

The nature and method of the proposed permanent cosmetic (cosmetic tattoo) procedure has been explained by my technician including the usual risks inherent in the tattooing process, and the possiblity of complications during or following its performance. I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effect may include minor and temporary bleeding, bruising, redness, or other discolouration and swelling. Fever blisters may occur on the lips following lip procedures. Fading or loss of pigment may occur. Secondary infection in the area of the procedure may occur; however, if properly cared for, is rare.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:*

Address:

Postcode:

Date of birth:*

You must be 18 or older

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.