PMU Informed Consent
General Consent
I am over the age of 18, am not under the influence of drugs or alcohol, am notpregnant or nursing and desire to receive the indicated semi-permanent pigmentation procedure. The general nature ofcosmetic 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 judgmentto decide what he/she feels is necessary under the given circumstances. I accept the responsibility for determining the color,shape and position of the Permanent Makeup procedure as agreed during consultation. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years. Even once thecolor 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 containersare used for each individual client, procedure and visit.
I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired resultsand 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 orthin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care.
Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In somecases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessiveperspiration and exposure to the sun should be limited until the skin has fully healed. Please see after care instructions for moredetails. The procedure results will look acceptable for you to appear in public without additional make-up.
I have been advised that the true color will be seen 6 weeks after each procedure, and that the pigment may vary according toskin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guaranteeon 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 adirect 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. Failureto do so may jeopardize my chances for a successful procedure.
I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity fordiscussion and to ask questions, and that I hereby consent to the procedure described above.
I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. Iunderstand the permanent skin pigmentation procedure carries with it known and unknown complications and consequencesassociated 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 ofmy skin.
I fully understand this is a tattoo process and therefore not an exact science but an art. I request the semi- permanent skinpigmentation procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences ofthe said procedure.
There is a possibility of an allergic reaction to numbing agent and/or pigments.
A patch test is offered however it does not ensure aclient will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to thepigment.
Initial one or the other, not both: I consent to the patch test OR I waive the patch test.
I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedures, itmay result in adverse changes to my permanent makeup procedure. I acknowledge some of these potential adverse changes may notbe correctable.
I certify that I have read and initialed the above paragraphs and have had explained to my understanding the consent and procedurepermit. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.
PMU PATCH TEST
I understand that I am receiving a patch testfor permanent makeup from Cosmetic Professional, a licensed and certified permanent makeup artist. Iunderstand that this test will help determine whether I am allergic to the permanent makeup pigment that will beused during my permanent makeup procedure.
I understand that the patch test will involve applying a small amount of pigment to a small area on my skin, andthat I will need to wait for 24-48 hours to observe any allergic reactions. I understand that if I experience anyredness, itching, swelling, or other symptoms, I must contact the artist immediately.
I understand that the patch test is not a guarantee that I will not experience an allergic reaction during thepermanent makeup procedure, but it can help reduce the risk. I understand that if I do experience an allergicreaction during the procedure, the artist will stop the procedure immediately and take appropriate action tomitigate any further risk.
I hereby give my informed consent to receive the patch test for permanent makeup, and I waive any claims orliability against the artist for any adverse reactions or injuries that may result from the patch test.
Photo & Video
I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or videotape without payment or any other consideration. I understand that my image may be edited, copied, exhibited,published or distributed and waive the right to inspect or approve the finished product wherein my likenessappears.
Additionally, I waive any right to royalties or other compensation arising or related to the use of my image orrecording. I also understand that this material may be used in diverse educational settings within an unrestrictedgeographic area.
Photographic, audio or video recordings may be used for the following purposes:
conference presentations,
educational presentations or courses,
informational presentations,
on-line educational courses,
educational videos.
By signing this release I understand this permission signifies that photographic or video recordings of me may beelectronically displayed via the Internet or in the public educational setting.
I will be consulted about the use of the photographs or video recording for any purpose other than those listedabove.
There is no time limit on the validity of this release nor is there any geographic limitation on where thesematerials may be distributed.
This release applies to photographic, audio or video recordings collected as part of the sessions listed on thisdocument only.
By signing this form I acknowledge that I have completely read and fully understand the above release andagree to be bound thereby. I hereby release any and all claims against any person or organization utilizingthis material for educational purposes.