Permanent Makeup Consent

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Your Body Artist: Nayeli Escalante Santos

Contact Email: ammicco@mail.com

Please read and acknowledge the following:

Date of Birth *

YYYY

FULL Legal Name *

Phone Number *

Address *

Risk Notification

There are risks and possible consequences of a body art procedure. They include, but are not limited to, the following: Body art can cause swelling, bruising, discomfort, bleeding and pain. Body art can cause allergic reactions. Body art can cause irreversible changes to the human body; and body art has a risk of infection. Any effective removal of the body art work may leave permanent scarring and disfigurement.

Evaluation for Procedure

Consult a physician prior to the procedure if you have any concerns about any of the questions below:

Have you eaten within the past 4 hours? *

Yes

Are you under the influence of drugs or alcohol? *

Yes

Have you ingested anticoagulants (such as heparin or warfarin), antiplatelet drugs, or nonsteroidal anti-inflammatory drugs (NSAIDS) (such as aspirin, ibuprofen, etcc.) in the last 24 hours? *

Yes

Have you ingested any medication that can inhibit the ability to heal a skin wound? *

Yes

Do you have any allergies or adverse reactions to dyes, pigments, latex, iodine, or other such products? *

Yes

Do you have hemophilia, epilepsy, a history of seizure, fainting, narcolepsy, or other conditions that could interfere with the body art procedure? *

Yes

Do you have any diseases that might inhibit the healing of the body are procedure? *

Yes

Do you have any communicable diseases (i.e., hepatitis A, hepatitis B, HIV, or any other disease) that could be transmitted to another person during the procedure? *

Yes

Do you have diabetes, high blood pressure, heart condition, heart disease, or any other conditions that could interfere with the body art procedure? *

Yes

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