CONSENT FORM – Cosmetic Tattoo
1. Do you presently or have you previously had any of the following:
History of MRSABOTOXDiabetesHepatitis (A, B, C, D) or Jaundice (last 12 months or ever)Forehead/Brow LiftEasy BleedingAlcoholismAbnormal Heart ConditionChemical Peel (Last Treatment):Pregnant/Breast Feeding NowAutoimmune DisorderOily SkinCancerChemotherapy/RadiationAccutane or Acne TreatmentTanning (Booth or Sun)Tumors/Growth/CystsBlood Thinners (Aspirin, Ibuprofen, Coumadin etc.)
If you selected BOTOX, please list last treatment:
If you selected CHEMICAL PEEL, please list last treatment:
If you selected CANCER, please note how many year(s):
2. Allergic Reaction to ANY medications/ List:
3. Diseases or Disorders NOT listed above:
4. Allergies (Metals, Food, Etc.) List:
5. Past or Present use of skin products w/ (Retin A, Glycolic Acid, Alpha Hydroxyl) & date of use:
6. Please list all Medications/Vitamins you’re CURRENTLY taking OR discontinued in the last 7 days:
*Disclaimer It is required that you, the client, consult with your Physician prior to taking, altering or stopping any form of medication and/or supplements, or making changes to your medication dosing cycles!!
Unfortunately, not everyone is a good fit for the lip blush and/or brow procedure. The following is a list of contraindications for the lip blush and/or brow treatment:
- Under 18 years of age
- Pregnant or lactating women
- Any skin issue, such as psoriasis, eczema and undiagnosed rashes or blisters on the site that is to be treated
- Allergies to makeup or colors
- Easily triggered post inflammatory hyper pigmentation
- Transmittable blood conditions like HIV or Hepatitis
- Active skin cancer in the area to be tattooed
- Healing disorders
- Blood thinners (consult with your physician)
- Uncontrolled high blood pressure or mitral valve disorder
- Accutane or steroids (consult with your physician)
- LIP BLUSH CLIENT ONLY - History of cold sores (if so, consult with your physician. Many clients avoid cold sore breakouts by taking a Valtrex cycle prior to their appointment.
Please read and check the box to accept:
STATEMENT OF UNDERSTANDING
This form is designed to give information needed to make an informed choice of whether or not to undergo a Semi–Permanent make-up application. If you have questions, please do not hesitate to ask. Permanent Makeup/Cosmetic Tattooing procedures are very effective, however, no guaranteed can be made that a specific client will benefit from the procedure.
This is the process of inserting pigment into the dermal layer of the skin; a form of tattooing. All instruments that enter the skin or come in contact with body fluids are STERILE, disposable and disposed of after use. Cross contamination guidelines are strictly adhered to.
Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is common to expect touch-ups after healing is completed. Initially, the color will appear much more vibrant or darker compared to the
end result. Usually within 7 days, the color will fade 50% + (soften and look more natural). The pigment is semi-permanent and will fade over time and will likely need to be touched up within 6 months to 2 years.
Possible Risks / Hazards / Complications:
- PAIN: There could be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.
- INFECTIONS: Infection is very unusual. Less than a 0.25% of the population has an allergic reaction. The areas treated must be kept clean and only touched with freshly cleaned hands. You must follow the specific after care instructions provided to you.
- UNEVEN PIGMENT: This can be a result of poor healing, infection, bleeding, or other causes. Your follow up appointment will likely correct any uneven appearances.
- ASYMMETRY: Every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness.
- EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. It typically disappears within 1-5 days. Some people do not bruise or swell at all.
- ANESTHESIA: Topical anesthetics are used for numbing the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform your technician IMMEDIATELY.
- MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low-level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI technician of any tattoos or
- ALLERGIC REACTION: There is a small possibility of an allergic reaction.
- Follow Pre-care instructions
- Follow After-care instructions
- Be truthful when answering ALL questions
- Be on time
- When in DOUBT ask questions
- No children allowed
- Please turn cell phones to vibrate/mute/airplane mode
- No smoking during procedure
I agree to Monarch Cosmetic Tattoo’s cancellation and etiquette policies. I understand that:
**IF I CANCEL WITHIN 48 HR (DEPOSIT IS NON-REFUNDABLE) @ 702-802-9634 VOICE/TEXT
Image Waiver Consent:
In case of emergency, contact:
PERMANENT COSMETICS WAIVER AND RELEASE FORM
I authorize my Cosmetic Tattoo Artist professional at Monarch Cosmetic Tattoo to perform the Cosmetic Tattoo/Permanent Cosmetics procedure. The risks of the cosmetic procedure I have chosen have been disclosed to me. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made, and I acknowledge that I have received no particular representations or guarantees, and I am consenting to the procedure at my own risk. I have revealed or disclosed on the Medical Profile form ALL conditions and circumstances regarding my health and health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could occur or be discovered during or after the procedure, which could affect my ability to tolerate the procedure.p>
I understand the success of my Cosmetic Tattoo/Permanent Makeup process requires my careful pre/post-care and maintenance. I understand that I must strictly adhere to all aftercare instructions. I understand that failure to follow
after-care instructions may result in infection, pigment loss, or discoloration. I agree to and understand all of the above information and consent that all of the information is correct to the best of my knowledge.
**I, as herein signed, release, give up, acquit and discharge my Cosmetic Tattoo/Permanent Cosmetic Artist and/or anyone affiliated with Monarch Cosmetic Tattoo, from any claims or damages of any nature. I agree to pay any costs of legal services necessary to further effect or confirm said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this waiver and release form, and said damages are specifically waived following the signing of this waiver and release form.
I further agree to hold my Cosmetic Tattoo/Permanent Cosmetic Artist nameless and harmless from any and all damages. I release my Cosmetic Tattoo/Permanent Cosmetic Artist from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure. I understand that I am responsible for any medical treatment I may need as a result of getting this procedure. I accept full responsibility for these and any other complications, which may arise or result during or following my procedure, which is to be performed at my request.
Please read the following statement and sign and date on the line to indicate that you have read, understand and accept the following statement:
I, the client herein signed, certify that I have read and had explained to me and fully understand the above waiver and release form. I certify that I have been consulted with a Cosmetic Tattoo/Permanent Cosmetic Artist and have
read all applicable literature given to me. I have completed the above forms to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully
capable of executing this waiver and release form for myself. I, the undersigned client, acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time. I, the client herein
signed, for the purposes of documentation, hereby consent to “before and after” photographs, which may or may not be used for the purposes of advertising.
Electronic Signature Consent:
By signing this form, I agree that my typed, electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten
signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
I understand and agree to the below electronic signature consent information provided.
CLIENT SIGNATURE & DATE: