Please read and sign.
I am over the age of 18, am not under the influence of drugs or alcohol, am
not pregnant or nursing and desire to receive the indicated semi-permanent procedure. The general nature of
cosmetic micro-pigmentation, as well as the specific procedure to be performed, has been explained to me.
- If an unforeseen condition arises in the course of the procedure, I authorize my therapist to use his/her
professional judgment to decide what he/she feels is necessary under the given circumstances. I accept the
responsibility for determining the color, shape and position of the procedure being performed as agreed during
pre-drawing on day of procedure. I fully understand and accept that nontoxic pigments are used during the
procedure and that the result achieved may fade over a period of 1-3 years. Even once the color fades,
pigment itself may stay in the skin indefinitely.
- I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and
pigment containers are used for each individual client, procedure and visit.
- I understand and accept that semi-permanent makeup is a process requiring multiple applications of
pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I
understand that I may have to return for a repeat procedure.
- The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure
after care.
- I understand that with oily skin types, strokes can heal less crisp, expanded and/or blurry and may result in a
powder-brow effect. (Eyebrow procedures)
- Upon completion of the procedure there might be swelling and redness of the skin, which will subside within
1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure,
however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has
fully healed. Please see after care instructions for more details. The procedure results will look acceptable for
you to appear in public without additional make-up on the treated area.
- I have been advised that the true color will be seen 6 weeks after each procedure, and that the pigment may
vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept
pigment more readily and no guarantee on exact color can be given.
- To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my
well being as a direct or indirect result of my decision to have the procedure done at this time.
- I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the
technician. Failure to do so may jeopardize my chances for a successful procedure. I can confirm that I have
received a copy of after care details.
I have been informed of the nature, risks, and possible complications and consequences of permanent skin
pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown
complications and consequences associated with this type of cosmetic procedure, including but not limited to:
infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual
color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a
tattoo process and therefore not an exact science but an art. I request the semipermanent skin pigmentation
procedure(s) and accept the permanence of this procedure as well as the possible complications and
consequences of the said procedure (initial)
