Elael'a Esthetics By Elegance

CONSENT TO APPLICATION OF PERMANENT MAKEUP

First name

Last name

Birthday

Month

Day

Year

Address

Phone

Emergency Contact Name

Emergency Contact Phone

Date of Procedure

CLIENT HEALTH CONDITION/MEDICAL HISTORY

To perform the facial skin treatment in a safe manner and to provide you with the most appropriate treatment, please answer the following health questions truthfully. All the information is confidential and will not be share with a third party.

Please check all that apply.

Are you currently under the care of a physician?

Do you suffer from any blood disorder?

Do you have diabetes?

Are you HIV +?

Do you have any type of hepatitis?

Do you have a history of skin sensitivity (eczema or atopic dermatitis)?

Do you have allergies to medications, food, metals, makeup or any other compound?

Do you suffer from any skin conditions? (Rosacea, Impetigo, Erysipelas, Lupus, Scleroderma, or any other disease?)

Do you suffer from any acute or chronic infectious disease?

Do you have epilepsy or any other seizure related condition?

Do you have any autoimmune disorder?

Are you prone to cold sores (herpes) or fever blisters?

Are you pregnant?

Are you breastfeeding?

Do you have a pacemaker?

Do you have any heart-related problems?

Have you consumed drugs or alcohol in the past 24 hours?

Have you had laser or chemical peels within 6 months?

Is your skin oily?

Do you take any prescribed medications on a daily basis?

Do you wear contact lenses?

Do you have any problems healing from wounds?

Do you have your period at the time of treatment?

Do you tend to develop keloid or hypertrophic scars?

Do you scar easily from minor skin injuries?

Did you undergo surgery or any other medical procedures in the last 14 days?

Do you have prosthetic implants?

Have you ever had PMU or any cosmetic treatment?

Do you personally have a history of cancer?

Do you have any problems healing from wounds?

Have you ever had an allergic reaction to lidocaine?

Are you now or have you ever been on the acne treatment, Accutane?

Do you have a tendency to develop dark spots on the skin from wounds or sun?

Do you routinely use Retinol-A, glycol, or other exfoliating products?

Are you currently undergoing radiation or chemotherapy treatment?

Do you bleed excessively from minor cuts?

If you had PMU or any other cosmetic treatment, did you have any problems with healing after they were applied?

Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antibiotic to a dental or other invasive procedure?

Do you form thick or raised scars from cuts or burns?

Have you ever had an allergic reaction to latex?

Comments (Please provide explanations for any questions you checked.)

Any additional medical information that would be important for the technician to know:

I certify that the preceding medical, personal, and skin history statements are true and correct.

I am aware that it is my responsibility to inform the technician of my current medical or health conditions to update this history.

Signature

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I certify that I am over the age of 18, I am not under the influence of drugs or alcohol, I am not pregnant or nursing, and I consent to receiving the indicated micropigmentation or permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to

me.

Consent with your initials.

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. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. 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 permanent skin pigmentation procedure/s, and accept the permanence of the procedure as well as the possible complications of the said procedure/s.

Consent with your initials.

There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to the pigment. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.

Consent with your initials.

I have received pre- and post-procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood-altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.

Consent with your initials.

I understand that before and after photographs of the said procedure/s are conditions of such procedure/s. I certify I have read and initialed the above paragraphs and have had explained to my understanding this

consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done and understand that there is a no refund policy. I understand that the cost of touch-up’s are not included in the procedure and the cost of touch up’s differs as time lapses from the original date procedure was dine.

Consent with your initials.

I agree on photos taken of my face and the use of said photos for advertising purposes.

Consent with your initials.

I acknowledge by signing the consent form, I have been given the full opportunity to ask any and all questions about the procedures and process from the practitioner/technician. I received clear and understandable responses to all my questions.

Consent with your initials.

Signature

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LUXURY TREATMENTS DESIGNED TO ENHANCE, CORRECT, AND RESTORE.

CONSENT TO APPLICATION OF PERMANENT MAKEUP

CLIENT HEALTH CONDITION/MEDICAL HISTORY