STATEMENT OF CONSENT AND RECITALS:

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I acknowledge that the information that i have provided in the medical questionnaire is complete and true to the best of my knowledge. (ENTER INITIALS BELOW) *

I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness, and burning may occur. (ENTER INITIALS BELOW) *

I understand that retin A, vitamin A, vitamin C, renova, retinol, alpha hydroxy, and glycolic acids must not be used on the treated areas. It will lighten the color and cause premature exfoliation of the pigment. (ENTER INITIALS BELOW) *

I understand that tanning beds, pools, some skin care products and medication can affect my permanent make up.(ENTER INITIALS BELOW) *

I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. (ENTER INITIALS BELOW) *

I accept the responsibility to explain to you by desire of specific colors, shape, and placement for any procedure done today. (ENTER INITIALS BELOW) *

I have been advised that a touch up session is highly recommended to make any adjustments to shape, color, and to fill in any pigment that may have had poor retention. Touch ups must be completed within 8-12 weeks of initial procedure. (ENTER INITIALS BELOW) *

I understand that any medical information obtained will be subject to the Federal Health Insurance Portability and Accountability Act of 1968 (HIPPA). (ENTER INITIALS BELOW) *

I certify that I have read and have had read to me the consents of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize my Semi Permanent Cosmetic Specialist to perform the procedure selected on my body.

Client Full Name (As shown on ID) and Date: *

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