Disclosure and Release: Lip Pigmentation

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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.

That I read, write and speak English sufficiently enough to understand these terms.

That there is a small possibility of bleeding and or swelling.

That there is a potential for discomfort during the procedure and the healing process.

That I have never had an adverse reaction to pigment or tattoos in the past.

That no promise or guarantee has been made by Elevate Lash Lounge Inc. or any of its representatives with reference to the outcome of this procedure.

That this procedure, though highly unlikely, may cause scarring or a keloid scar to form.

That there may be a risks or hazards related to this procedure.

That if I am unable to personally tolerate the discomfort of the procedure, my payment is 100% non-refundable and may not be able to perform this procedure on me.

That I have never been diagnosed with or have reason to believe that I have any type of skin disorder or blood disease.

That I have no known allergies, including but not limited to allergies to fruits and or vegetables.

Medical history form. For example pain control medications, it may cause blood to thin and cause excessive bleeding to occur.

That it is my sole responsibility to advise the technician of any concerns I may have before the procedure begins, even though I have written it down on the medical history forms.

That I've had the opportunity to ask questions regarding the procedure their desk and hazards involved in the procedures and the questions have been answered to my satisfaction.

That pigment may not hold in certain skin types. Such as but not limited to, excessively oily or dry skin or clients with adult acne. Individual results may vary.

That I am confident that I have sufficient information to give this informed consent and proceed with this procedure.

That I am not currently under the influence of alcohol or drugs or any other substances.

I am over 18 years of age.

I understand and consent that my before and after images be used by Elevate Lash Lounge Inc for marketing purposes, i.e website, Facebook or print material, advertising, will keep my identity anonymous. (Leave this uncheck if you don't want your photos to be used)

Required

I agree to the following pre-appointment instructions:
*

You do not consume alcohol, caffeine or blood thinners (aspirin, ibuprofen, Niacin, fish/primrose oil) 48 hours before your PMU procedure.

Avoid laser, facials, botox / fillers, chemical peels, exfoliation and retinol product within 3 to 4 weeks of your cosmetic tattoo.

Please avoid tanning bed & sun exposure for 30 days BEFORE and AFTER your PMU procedure. This is crucial to achieve the best healed results! As your skin exfoliates from a tan or sunburn, it will take the tattoo pigment with it- therefore if you arrive with signs of sun exposure, we will unfortunately have to reschedule your appointment and you will forfeit your deposit.

Required

We would like your permission to use these photos for advertising. For example: portfolios, online and print ads, etc. Your consent is necessary regarding this. Please check next to the line and indicate with your signature if you would like your photos used or not used in advertising

Yes, feel free to use them.

No, please do not use them

Full Name *

Date of Birth *

Instagram/Facebook Account *

List any allergies : (write none, if there isn't any) *

List of any current medications you are taking (Prescribe or not) (write none, if there isn't any)
*

Have you ever had an adverse reaction to pigment?
*

Yes

Do you have any allergies to fruits or vegetables?
*

Yes

Do you have or suffer from any of the following:
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Diabetes

Hormone imbalance

Depression/Anxiety

Epilepsy

Pregnant or breastfeeding

Hypoglycemia

Blood thinners

Cold sores

Heart condition

MRI in the near future

Hepatitis or jaundice

Mental illnesses

Anemia

Herpes

Keloid scar

Asthma

HIV/AIDS

Bleeding disorder

Constipation

Cancer

Hemophilia

Contact lenses

High blood pressure

Pacemaker

Dermatitis/Eczema

None of the above

Required

Write any area (s) were you had or have skin condition or surgery: (Write none, if there isn't any)
*

List conditions or surgery (write none, if there isn't any)
*

In case of emergency:

Name of a local friend or relative:

Relationship to client:

Cellphone Number:

Work Phone Number:

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

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

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