CONSENT FOR PERMANENT MAKEUP REMOVAL (PIGMENT LIGHTENING/REMOVAL)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

Full Name *

Date *

Please read this legal document carefully.

You are required to check next to each statement. By checking each statements, you confirm and acknowledge that you have read fully, understand and accept each of the terms and conditions below relating to your procedure.

The nature and method of proposed permanent makeup (tattoo) lightening procedure has been explained to me, including risks or possibility 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 the other adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fever blisters may occur on the lips (following lip procedures) and individuals prone to this problem period secondary infection in the area of the procedure may occur, however if properly cared for, this is rare.

I understand that several treatments may be needed in order to attempt to achieve my desired results.

However, I have not received any guarantees as to the final outcome of these treatments whatsoever.

I understand there are medical options available for permanent makeup (tattoo) removal, which includes excision and cutting of the tattoo. I have decided to decline those methods.

I understand that the unwanted pigment may not be successfully lightening to the point that it can no longer be seen. Scarring as hyperpigmentation or hypo pigmentation, or other damages to the skin may occur during this process and may be permanent period I will not hold my technician and or the distributor of tattoo/pigment removal products used in this attempted permanent makeup (tattoo) removal/lightning liable for any damages that may occur to the person.

Required

I agree to the following pre-appointment instructions:
*

Your skin musn’t be tanned or sunburned.

You should be hydrated properly.

Avoid shaving, waxing, and exfoliating the area.

Don’t take any aspirin or anti-inflammatory drugs, as these can sometimes increase bleeding.

Required

Which of the following best describes your skin type? (Please choose one)
*

Always burns, never tans

Always burns, sometimes tans

Sometimes burns, always tans

Rarely burns, always tans

Brown moderately pigmented skin

Black skin

For skin types V and VI only, use saline removal only:

I understand that I am at a higher risk for hyperpigmentation and hypo-pigmentation than other skin types. I agree to take the risk involved.

I understand that lightening tattoo pigment is difficult, if even possible. As a result, I will not hold my technician or this establishment responsible for any resultant failure to lighten the unwanted pigment.

I agree to submit before and after photographs, and give my permission to use such photographs for publication and/or teaching purposes.

I agree to follow all aftercare instructions provided to me by my permanent makeup removal technician at Elevate Lash Lounge, Nelson BC.

I've been duly informed of the natures, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor.

I understand all information listed above, have had my questions answered, and agree to all conditions and provisions of this document as evident by my signature below. I accept the risks for having this procedure done.

I consent and give approval to the technician doing my treatment to use and apply anesthetics which contain: Lidocaine, Tetracaine, Prilocaine, and Epinephrine. This will be used before and during the treatment.

I am over 18 years of age and consent to the agreement and to treatment.

I release my technician or salon from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use.

Required

Date of Birth *

Instagram/Facebook Account *

I acknowledge that Elevate Lash Lounge is strictly open by appointment only.

I agree to come ON TIME but NOT EARLY to my appointment to give time for the staff to properly prepare for my appointment & out of consideration to previously booked clients.

Required

I hereby grant permission to Elevate Lash Lounge Inc to take photos or videos during service for promotional, educational or marketing purposes.

By submitting this consent form, I verify that I have read and understand the above statements and agree to them.

I acknowledge that this consent form is legally binding & submitting this indicates that I agree & signed to it.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Elevate Lash Lounge.

Does this form look suspicious? Report

Forms