Consent Form

Your one step away from starting your treatment...

This informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure you are about to undertake.

This material serves as a supplement to the discussion you have with your doctor/healthcare/medical provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/ healthcare professional prior to signing the consent form.

I understand permanent makeup is a form of tattoo that requires implantation of pigment into my skin using a needle. I understand there may be risks and hazards related to the performance of this procedure, including but not limited to: allergic reaction to the pigment/other products that will be used, lightheadedness, bleeding, bruising, swelling, scarring, and infection.

PUBLICITY MATERIALS I authorise the taking of clinical photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.
Please enable JavaScript in your browser to complete this form.
Name
I am at least 18 years of age
Are you pregnant or breastfeeding?
Are you under the influence of alcohol, drugs, or any other substances?
Have you had Botox/Dysport or any fillers in the last two weeks?
Are you currently using any products containing Retin-A or Hyaluronic Acid? (or similar ingredient?)
Do you use any medication that may affect the healing procedure? If so please list:
Please list any medication in the box above.
Are you allergic to Latex?
Are you allergic to Shellfish/Iodine?
Are you allergic to Lavender?
Do you have Diabetes?
Do you have Epilepsy?
Do you have any heart conditions?
Do you have Hemophilia?
Are you suffering from Asthma?
Are you currently taking blood thinner medications?
Are you suffering from Herpes (cold sores)?
Do you or have you suffered from any skin conditions including eczema, psoriasis or keloid scars?
Have you suffered from fainting/dizziness?
Please type any additional info you may want me to know before your appointment.

Consent Form

Your one step away from starting your treatment...

This informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure you are about to undertake.

This material serves as a supplement to the discussion you have with your doctor/healthcare/medical provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/ healthcare professional prior to signing the consent form.

I understand permanent makeup is a form of tattoo that requires implantation of pigment into my skin using a needle. I understand there may be risks and hazards related to the performance of this procedure, including but not limited to: allergic reaction to the pigment/other products that will be used, lightheadedness, bleeding, bruising, swelling, scarring, and infection.

PUBLICITY MATERIALS I authorise the taking of clinical photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs.
Please enable JavaScript in your browser to complete this form.
Name
I am at least 18 years of age
Are you pregnant or breastfeeding?
Are you under the influence of alcohol, drugs, or any other substances?
Have you had Botox/Dysport or any fillers in the last two weeks?
Are you currently using any products containing Retin-A or Hyaluronic Acid? (or similar ingredient?)
Do you use any medication that may affect the healing procedure? If so please list:
Please list any medication in the box above.
Are you allergic to Latex?
Are you allergic to Shellfish/Iodine?
Are you allergic to Lavender?
Do you have Diabetes?
Do you have Epilepsy?
Do you have any heart conditions?
Do you have Hemophilia?
Are you suffering from Asthma?
Are you currently taking blood thinner medications?
Are you suffering from Herpes (cold sores)?
Do you or have you suffered from any skin conditions including eczema, psoriasis or keloid scars?
Have you suffered from fainting/dizziness?
Please type any additional info you may want me to know before your appointment.

I love the confidence that makeup gives me - Tyra Banks

#LIPBLUSHEDBEAUTYBYRIA

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