Cosmetic Tattoo Informed Consent
I am at least 18 years of age. I am not under the influence of drugs or alcohol. I accept any and all responsibility for consequences that might stem from my decision to have the cosmetic or permanent make-up tattoo process. I have, of my own free will, elected to have this cosmetic or permanent make-up tattoo procedure and consent to the application of the procedure and to its attended risks, and to any actions or conduct of the practitioner reasonably necessary to perform the procedure(s).
The nature and method of purposed cosmetic tattoo procedure(s) has been explained by the technician, the risks inherent in the procedure process, and the possibility of complications and have been given the opportunity to ask questions. I understand there may be a certain amount of discomfort or pain associated with the procedure(s) and that other adverse side effects may include minor and temporary bleeding, bruising, swelling, and/or redness or other discolorations. Fading or loss of pigment may occur. Unevenness in design may occur due to swelling. Secondary infection in the area of procedure may occur, however, if all aftercare instructions (that were provided) are followed, is rare. By executing this form, you agree that a technician’s representative has reviewed cosmetic tattoo procedures and processes with you, and addressed all your questions and concerns.
To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my wellbeing as a direct or indirect result of my decision to having cosmetic or permanent make-up tattoo procedures. I do not have any health issues that would prevent me from having the cosmetic tattoo process applied by the technician or its employees. I will advise my technician if I have any condition that may affect the healing from this kind of procedure such as diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS, or any other communicable disease, heart condition or take medication which things the blood. I will inform the technician of any health problems or changes.
This cosmetic, elective, non-medical procedure is being performed using standard aseptic technique and sterilization methods recommended by the Center for Disease Control. This inludes the dispensing of all consumables for single use on one client in front of the client The device used for implanting pigment can be disassembled and the non-motor parts discarded.
I have fully informed in regards to the procedure of cosmetic or permanent make-up tattoo related procedures. It has been explained to me the typical results of my elective procedure may be, however, complications may occur that include corneal abrasion, fever blisters, redness, swelling, bruising, tingling and discomfort, infection, scaring, and allergic reactions. I have been advised specifically with regard to possible allergic reaction to a local anesthetic or preservatives, solutions, pigments and latex. I understand allergic reactions may occur, sometimes severe, with permanent cosmetic pigments at any point in time. Understand the risk, I wish to have permanent cosmetic tattoo procedure(s).
The technician has explained to me what the typical result of procedures following a previous technicians work, whether correction, with or without removal, color refresher/booster. No promises or guarantees of any kind have been made to the final outcome. Pigment may not retain in the area of tattoo removal due to damaged tissue and scaring. Pigment may not retain over previous procedures or work, due to the saturation level of pigment and/or scar tissue caused from the previous work. Complications may occur that include hypopigmentation, hyperpigmentation, corneal abrasion, fever blisters, redness, swelling, bruising, tingling and discomfort, infection, scaring, and an increased risk of allergic reaction occurring. I have been advised that using another supplier’s pigment over my existing can encourage this reaction.
I acknowledge that complications are always possible as a result of the cosmetic tattoo procedure, particularly if aftercare instructions are not followed. I have received a written copy of pretreatment and aftercare instructions and will follow them while the procedure area is healing. I will contact the technician with any all questions and concerns that may arise.
I full understand that the permanent cosmetic tattoo procedure(s) are a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove it in the future.
I fully understand there is no pigment or ink FDA approved for the purpose of any type tattooing.
Tattoo removal, previous permanent make-up, Alopecia, Trichotillomania, skin conditions, or scars in the procedure area, due to tissue and skin healing, you may require multiple procedures and/or there’s a chance the pigment may not retain at all.
I give permission without restriction to allow all photography of the treated area and may include full face photos of before, during and after the procedure, and final healed result for use in the technician, it’s employees’ or contractors’ portfolios, website and advertising.
I have been advised this procedure will be video and sound recorded for verification of sanitation and disinfection to meet the standards recommended by the Center for Disease Control.
I understand that should it be decided that any client cannot continue a procedure, due to too much movement, safety issues, personal tolerance or any other reason, once the procedure has been started, it will then be considered completed and applicable fee will be due in full. Said procedure will not be rescheduled or refunded. There will be additional fees for any ongoing procedures.
I understand that the technician may request a Physicians Medical Release; it must state you qualify for cosmetic tattoo procedures, be signed, dated and emailed to the technician directly from the physician’s office. This release is required prior to scheduling or receiving a procedure.
I understand that I may not be able to donate and/or sell blood for 1 year after any procedure.
Titanium Dioxide is an ingredient used in micropigmentation colors. Lasers can permanently alter the color of titanium dioxide of micropigmentation tattoos and may not be able to be removed and/or corrected.
I understand that a MRI may be affected by the application of tattooed permanent make-up. It is understood that I will advise my physician that I have cosmetic tattooing in the event an MRI is prescribed. For more information, visit www.MRIsafety.com._(inti.)
This contract will remain in full effect for as long as I am a client of the technician and all of its contents will apply whenever work is being performed on myself by the technician. It is my responsibility to inform the technician if changes have occurred in my medical/health history.
I have been fully advised of the risks associated with this procedure and cosmetic tattooing is an art form and NOT an exact science. I acknowledge that NO guarantees have been made as to the final result of this procedure and the necessary steps that it will take to remove and/or correct the cosmetic or permanent make-up tattoo I am receiving.
I accept full responsibility for determining color, shape and position of the pigments that will be applied. I understand that the actual healed color of the pigment applied will be modified slightly due to my own unique skin undertones.
Some skin types will not accept or heal pigment in a consistent manner…your skin and how well you take care of the procedure area will determine your result. I realize that my body and my skin is unique and that the technician cannot in any way predict how many visits it will take to complete my procedure.
It has been explained to me that immediately after the procedure(s) is completed, the color will appear darker and/or brighte r and the design will appear to be thicker. It has also been explained to me that within a short period of time (usually 5-7 days) during the healing process, the color will soften/lighten and the design will heal thinner than it looked the day it was performed.
I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), scarring is a possibility as a result of my body’s reaction to the skin being broken during the procedure. I realize the body is unique and that the technician cannot predict how my body will react as a result of this procedure.
I understand that future laser treatments, plastic surgery, implants or fillers and any other skin altering procedures may alter or degrade my cosmetic tattoo procedure(s). I further understand that such changes are NOT the responsibility of the technician, and such changes in my appearance my NOT be correctable though further cosmetic tattoo procedures._ (init.)
I fully understand that cosmetic and permanent make-up tattoo is permanent and can take repeat procedures to achieve the desired effect. The fee(s) for your cosmetic tattoo procedure(s) have been explained to me, including initial procedure fee, follow up fees and maintenance color refreshers/booster fees. Please refer to Our Policies. These fees are understood and agreed upon, I understand the total fee for services rendered is due upon completion of the initial procedure and there WILL BE separate fees for any follow up or ongoing procedures.
I accept full responsibility for determining the color, shape and position of the pigments that will be applied. I understand actual color of pigment may be modified slightly due to my own unqie skin tone, undertones and color of my skin.
Redheads, blondes, and fair skin will be red, swollen and pigment MAY not take. Additional procedures may be required to obtain desired results.
I acknowledge that hair stroke brow procedure pigment implanted in darker skin tones will appear softer and blend more with your own skins melanin and not appear as bold or crisp as on lighter skin tones.
Hair stroke eyebrow WILL with time and aging, become more solid and powdered looking. Frequent tanning and sun exposure WILL fade pigment quicker.
Smoknig will affect your results and may cause the pigment to fade prematurely.
I understand that if I have severely oily skin the pigment will appear much softer and hair strokes can look more solid due to the over-production of the oil glands. The pigment WILL fade quicker and may require more frequent color refresher/boosters.
I fully understand that with age and time that pigment may no longer retain in your skin. Color refreshers are recommended every 1-3 years or as needed to keep color fresh._ (init.)
I acknowledge that I have received a copy of detailed after care instructions in writing and will follow them. I agree to fol low the instructions concerning the care of my cosmetic tattoo while it is healing. I understand that after care is crucial for optimum results and if I do not follow the strict after care instructions, I can ruin my results. I will contact the technician with any all questions and concerns that may arise.
The technician can release me as client should I not be compliant with procedure polocies or elect to have another artist/technician apply cosmetic tattooing over an area originally done by the technician; I understand that I will no longer be a candidate for ongoing procedures or corrections provided by the technician.
Additional Details and / or Information
I acknowledge by signing this consent form that I have been given the full opportunity to ask any and all questions about cosmetic tattooing procedure, its process, and the risks involved by the technician. The decision to have cosmetic tattoo procedure(s) performed by The Technician is my own and I understand and accept all risks involved, therefore hereby releasing the technician, its employees, heirs and assigns from all manner of legal liabilities, claims, actions, and demands, in law or in equity, which I or my heirs have or might have now or hereafter by reason of complying with my request for said procedure. Cosmetic tattooing is not a medical procedure by an art form, the art of tattooing. I ACKNOWLEDGE THAT NO GUARANTEES OR PROMISSES HAVE BEEN MADE TO ME CONCERNING THE RESULTS OF THIS PROCEDURE AND THAT THE PROFESSIONAL RECOMMENDATION IS A NATURAL LOOK. Due to the fact your approval is obtained prior to final selection of color to be implanted and design application(s),that all the facts about cosmetic tattooing have been disclosed and discusses with you.
I, undersigned, have read each paragraph, understand, acknowledge and agree to all of the above terms and conditions.