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Disclosure and Consent for Tattoo and Dermal Procedures
I,_____________________________________, voluntarily request, as my permanent makeup artist, Jettie Watkins (and such association and technical assistance as she may deem necessary) to perform the following procedure(s) (circle one):
UPPER EYELID LOWER EYELID FULL LIP COLOR LIP LINER
COMBINATION BROW CORRECTION PROCEDURE other:
______(Must Initial) I hereby authorize Jettie Watkins to take photographs of the work performed both before and after treatment.
Please initial the one that you choose:
_______I acknowledge and give consent to Jettie Watkins to use images of my permanent makeup procedure for marketing and, or publishing purposes in various media such as the internet, Facebook, Instagram, Web pages, magazines, printed, and or television etc.
_______I hereby authorize Jettie Watkins to take photographs of the work performed both before and after treatment to be maintained only in file.
_______I do not want my photographs to be used for marketing/advertising purposes.
Please initial each line:
_______I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results.
_______I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment but not those that would have a delayed reaction.
________I understand that if I have Oily Skin that my PMU may not heal as crisp because of the overactive sebaceous glands in my skin.
______I acknowledge that obtaining permanent makeup is my choice alone. The application of permanent makeup will result in a permanent change to my appearance, and that needles and pigments will penetrate the surface of my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent makeup to the original condition, and it is very costly to remove.
________I am not pregnant or nursing.
________I have informed Jettie Watkins that I am in good health and not under the care of any physician.
_________I have advised the artist of any allergies to latex gloves, soap, or medications. I acknowledge it is not reasonable for the Jettie Watkins to determine whether I might have an allergic reaction to the permanent makeup procedure and further acknowledge that such reaction is possible.
________I have truthfully represented to Jettie Watkins that I am 18 years of age or older.
________I am not under the influence of any drugs or alcohol.
________To my knowledge, I do not have any physical, mental impairment or disability that might affect my well-being as a direct or in direct result of my decision to have permanent makeup at this time.
________I acknowledge infection is always possible as a result of permanent makeup application, and I agree to follow all suggested instructions concerning the care of the permanent makeup site while it is healing.
_______I understand I will have permanent makeup applied using appropriate instruments and sterilization techniques. I agree to release and forever discharge, and hold harmless, the artist, all employees, contractors, management and owners of Jettie Watkins from any and all claims of negligence, damages, or legal actions arising from connected in any way with my permanent makeup, the procedure, and conduct used in my permanent makeup procedure and assume all responsibility for the decisions made consenting to this procedure.
_______I have been told that allergic reactions to pigment are very rare, however, they can and do occur and when they occur they can be serious and especially difficult and very troublesome to treat, and I hold harmless Jettie Watkins, assistants, and pigment manufacturers from any and all liability associated with any adverse reaction(s).
_______I have been told that this procedure may involve pain and discomfort.
_______I understand the markings are permanent and that there is a possibility of hyper pigmentation resulting from a procedure, especially in individuals prone to hyperpigmentation from a scar or other injury.
_______I have been told that a follow up procedure will be required 6-8 weeks after initial treatment because results and retention can not be guaranteed.
_______I have been told that there is a chance that I may experience a corneal abrasion when getting eyeliner.
_______I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me.
_______I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.
_______I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Jettie Watkins, a healthcare practitioner, and The Department of Health, Drugs and Medical Devices Division: 1-888-839-6676.
_______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.
_______I have received a copy of the 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.
_______Guarantees and refunds are not given for work completed by Jettie Watkins, and all those associated with Primp Spa, LLC.
I Acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about PMU, and my questions have been fully and thoroughly (to my satisfaction) answered from Jettie Watkins. This form has been fully explained to me, and I have read or it has been read to me; I understand it, and I do not have any further questions.
Client Medical History
List all medications you are currently taking, including Retin A, Glycolic Acid and Acutane:
List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams):
Have you recently undergone a skin peel?
What products do you use that contain retinols, acids, or skin thinning and/or sensitizing agents?
Do you have or have you had any of the following conditions (answer Yes or No):
_________ Abnormal Heart Condition
_________ Cold Sores
_________ Herpes Simplex
_________ High or Low Blood Pressure
_________ Prolonged Bleeding
_________ Circulatory Problems
_________ Fainting Spells/Dizziness
_________ “Dry Eye”
_________ Corneal Abrasions
_________ Eye Surgery or Injury
_________ Blepharoplasty (eyelid surgery)
_________ Visual Disturbances
_________ Are you pregnant?
_________ Do you wear contact lenses?
_________ Do you use tobacco products?
_________ Are you using any eye drops or other ocular medications?
_________ Have you ever experienced hyper-pigmentation from an injury?
_________ Are you currently taking aspirin or ibuprofen or other blood thinning OTC
How much alcohol have you consumed in the last 48 hours?
By signing below I am acknowledging the information stated above is true and correct to my knowledge.
FOR ALL PROCEDURES:
(Eyebrows, Eyeliners, Lip Liner/Full Lips, Areola, and Camouflage)
Immediately Following Cosmetic Tattoo Procedure:
Apply ice to treated area for 10-30 minutes (if needed). Ice helps reduce swelling and aids in healing.
For 7-14 days following application of permanent cosmetics:
* Do not touch the healing pigmented area with your fingers. They may have bacteria on them and create an infection. Use a clean cotton swab, ideally sterile.
* After the first 24hrs gently wash PMU with a mild soap (ideally antibacterial) and warm water (not hot!). Continue this 1x/day until completely healed. If OILY SKIN gently wash 2x/day. Apply a thin layer of ointment after cleansing and before showering. (1 packet of Aquaphor should last the entire healing process).
* Do not rub or pick at the epithelial crust (scabs); allow it to flake off on its own. There should be absolutely no scrubbing, no cleansing creams or chemicals. Gently cleanse the intradermal cosmetic area with a mild antibacterial soap. You may rinse with water and lightly pat the area dry. Do not expose treated area to full pressure of the water in the shower.
* After bathing, gently apply a light coating of provided ointment on the procedure area using a clean cotton swab. Continue this regimen until the procedure area is healed.
* No makeup, tinting of lashes or brows, sun, soap, sauna, Jacuzzi, swimming in chlorine pools, ocean, rivers or lakes, contact with animals, gardening for 5-14 days, (or until the area is completely healed) post initial procedure and after all touch-ups.
* Let any scabbing or dry skin naturally exfoliate off. Picking can cause scarring.
* Avoid direct sun exposure or tanning for 3-4 weeks after procedure.
* Avoid heavy sweating for the first 7-14 days.
* If you have excessive redness, swelling or tenderness or any red streaks going from the procedure site toward the heart, elevated temperature, or purulent drainage from the procedure site, contact your physician as the area may be infected and you may need to seek medical care.
* Touch-up visits should be scheduled between 6-8 weeks post procedure. All permanent makeup procedures are a two step process. Results are not determined until touch-up application is completed.
* No facials, Botox, chemical treatments and microdermabrasion for 4 weeks.
* Avoid sleeping on your face for the first 7-14 days. Sleeping on a satin pillowcase is recommended for ALL PMU.
* If you have any questions or concerns please notify Jettie Watkins immediately.
* Touch-ups must be done within 8 weeks of the procedure, and will not be done before 6 weeks post procedure. After 8 weeks touch ups will cost $180.
* Failure to follow these instructions will result in pigment color loss and your work will not be guaranteed by technician!
* All permanent makeup procedures are a two-step process.
* We suggest a yearly “Color Boost” to maintain your procedure color integrity!
By signing below, I am acknowledging that I have read and understand the post procedures. Failure to follow post-treatment instructions will cause loss of pigment, discoloration or infection. Remember, colors appear brighter and more sharply defined immediately following the procedure. Results will not be considered final until 6-8 weeks post touch-up appointment, which will be scheduled 6-8 weeks after initial treatment.
PLEASE FEEL FREE TO CALL IF YOU HAVE ANY FURTHER QUESTIONS.
Enjoy your permanent cosmetics!