Permanent Makeup Consent Form

Permanent Makeup Consent Form

Consent Form For

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Personal Information

Your Name (required)

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History Information

Equipment Use

Consent and Sign

I read and agree the agreement below

Notice that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. The nature and method of the proposed cosmetic tattoo procedure(s) has been explained to me by Phuong Uyen Tran including the usual risks inherent in the procedure process, and the possibility of complications during and following the procedure(s). I understand there may be a certain amount of discomfort or pain associated with the procedure(s) and that other adverse side effects may include minor and temporary bleeding, bruising, swelling, and/or redness or other discolorations. Fading or loss of pigment may occur. Unevenness in design may occur due to swelling. Secondary infection in the area of the procedure may occur, however, if all aftercare instructions (that are provided) are followed, is rare. (init.) • I have informed Phuong Uyen Tran of any and all health problems. (init.) • I acknowledge that complications including infection are always possible as a result of a cosmetic tattoo procedure(s), particularly in the event my post-procedural instructions are not followed. (init.) • I acknowledge that it is not reasonably possible to determine whether I might have an allergic reaction to any of the pigments, dyes, topical preparations , or processes used in the procedure; and I agree to accept the risks that such a reaction although rare, is possible. I have informed Phuong Uyen Tran of any existing problems. (init.) • It has been explained to me that immediately after the procedure(s) is completed, the color will appear dark and the design will appear to be thicker. It has also been explained to me that within a short period of time (usually 5-7 days) during the healing process, the color will lighten/soften and the design/procedure will heal thinner than it looked the day it was performed. (init.) • I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), or scarring is a possibility as a result of my body's reaction to the skin being broken during the procedure. I realize that my body is unique and that Phuong Uyen Tran cannot predict how my body will react as a result of this procedure. (init.) • Applies to lip procedures only. I am aware that the Herpes Zoster 1 Virus (fever blisters or cold sores) may manifest with the lip procedure due to trauma to the lip tissue. The anticipation of a Herpes Zoster 1 Virus breakout may be and is advised to be pre-treated with an anti-viral medication, which are available by prescription only from your doctor. This is your responsibility. Although you medicate properly as advised with an anti-viral, this does not guarantee you will not have an outbreak. (init.) • I acknowledge that the procedure(s) will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. Tattoo removal is a surgical procedure which may cause scarring and/or disfigurement. (init.) • I understand that future laser treatments, plastic surgery, implants, injections, and other skin altering procedures may alter and degrade my cosmetic tattoo procedure(s). I further understand that such changes are NOT the responsibility of Phuong Uyen Tran, and such changes in my appearance may NOT be correctable through further cosmetic tattoo procedures. (init.) • I understand that tattoos may cause MRI (Magnetic Response Imaging) artifacts and that there may be a warming and/or tingling sensation in the tattooed area during the MRI due to the iron oxide properties of some pigments. It is understood that I should advise my physician that I do have permanent cosmetics (a tattoo) in the event an MRI procedure is prescribed. (init.) • I authorize Phuong Uyen Tran to obtain pre-procedural and post-procedural pictures, give her permission to use such pictures for publication and/or teaching purposes, as she chooses. (init.) • I acknowledge the receipt of written instructions advising me of the proper care of my procedure(s), and ointment by Phuong Uyen Tran. I understand the absolute necessity for following these instructions. (init.) • I understand that cosmetic tattooing is an art form and NOT an exact science, and I acknowledge that NO guarantees have been made to me as to the result of this procedure, and that the professional recommendation is a natural look. Some skin types will not accept or heal pigment in a consistent manner.. .your skin and how well you take care of your procedure (s) will determine your result. I realize that my body and my skin is unique and that Phuong Uyen Tran cannot in any way predict how your skin may react to the procedure or how it may or may not accept color. I also realize that Phuong Uyen Tran cannot predict how many visits it will take to complete my procedure. (init.) • The fee for your cosmetic tattoo procedure(s) have been explained to me, including the initial procedure fee, touch-up fees and maintenance fees. These fees are understood and agreed upon. I understand the total fee for services rendered is due upon completion of the initial procedure and that there WILL BE separate fees for any touch-up/ follow-up work. (init.) • I understand that Phuong Uyen Tran DOES NOT include a free touch-up appointment(s) in her initial procedure price. All touch-up/follow-up appointments ARE a separate fee. A "follow-up" appointment is often needed to complete, adjust, or fine tune the initial procedure or a maintenance procedure. All "basic" follow-up appointments will be charged a $75 set up fee and this fee will be guaranteed for 6 months only following your initial procedure date (with the exception of full lips which is $150). After 6 months the follow up fee will increase to $150 (lips increasing to $200). After one full year of initial procedure date, Maintenance fees will apply. (init.) • I accept full responsibility for determining the color, shape and position of the pigments that will be applied. I understand the actual healed color of the pigment applied will be modified slightly due to my own unique skin undertones. (init.) • I would like a patch test( requires r/s'ing) (init.) or Decline patch test. (init.) • Red Heads, blondes and fair skin (Fitz 1-2 skin types) will be red, swollen and pigment MAY not take. Additional procedures may be required to obtain desired results. (init.) • The eyebrows WILL with time and aging, become more solid and powdered looking (init.) • Results WILL appear softer as the treated area heals. The area/s treated WILL NOT look as crisp or as BOLD as the 1st procedure. ALL procedures require 2 appointments and color boost every 1-1 1⁄2 yrs to keep the color fresh. (init.) • I acknowledge and understand that if I have severely oily skin the pigment will appear much softer and can look more solid due to over-production of oil glands. The pigment WILL fade quicker and may require more frequent touch up(fees apply) (init.) • Frequent tanning and sun exposure WILL fade the pigment quicker. It is recommended to NOT have a tan/burn on your face at the time of your procedure. (init.) • I acknowledge and understand that pigment implanted on darker skin types( i.e. Indian, African American, Filipino and there like), will appear softer and blend more with your own skin melanin and will not appear as bold or crisp as on lighter skin types. (init.) • Alopecia clients- due to the change in skin texture, may require more frequent touch-ups, and in some cases, the pigment will not retain. (init.) • For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s). APPROVE (init.) DECLINE (init.) • I acknowledge that the obtaining of Permanent Makeup procedure(s) is by my choice alone, and I consent to the application of the procedure and to its attendant risks, and to any actions or conduct of the practitioner and/or any of the practitioner's associates reasonably necessary to perform the procedure(s). (init.) • If you have had tattoo removal prior to seeing Phuong Uyen Tran , due to scar tissue and skin healing , you may require multiple appointments and/or the pigment may not retain. (init.) • I understand that if any other technician applies permanent makeup over an area that was originally done by Phuong Uyen Tran, she will no longer perform future treatments, NO EXCEPTIONS! (init.) • Due to the fact your approval is obtained prior to final selection of color to be implanted and design application(s), that all the facts about cosmetic tattooing have either been disclosed or discussed with you, and that you have been given full opportunity to have any and all questions answered, Phuong Uyen Tran employs a NO REFUND policy. (init.) • I understand that if I do not abide by the strict after care, I can ruin my results. The AFTER CARE is CRUCIAL for optimum pigment retention. (init) • PMU by Phuong Uyen Tran can release me as a client at any time if I am not compliant with the procedure policies. (init.) • Phuong Uyen Tran has the right to refuse service to anyone at any time for any reason. (init.) • This contract is to remain in effect for as long as I remain a client of Phuong Uyen Tran and all its contents apply whenever work is being performed on myself by Phuong Uyen Tran. It is my responsibility to inform Phuong Uyen Tran if any changes have occurred in my medical history. (init.) • I have read and understand the contents of each paragraph above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of the above mentioned procedure(s). (init.) I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the above mentioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself. I (print name) , acknowledge by signing this consent form, have been given the full opportunity to ask any and all questions about cosmetic tattooing procedure(s), it's process, and the risks involved from Phuong Uyen Tran. The decision to have cosmetic tattooing procedure(s) performed is my own and I understand and accept all risks involved, therefore releasing Phuong Uyen Tran of any and all legal liability. Phuong Uyen Tran is an artist,a highly trained, experienced and skilled artist and makes no claims to be anything more. Permanent makeup/cosmetic tattooing is not a medical procedure but an art form, the art of tattooing. NO REFUNDS....NO EXCEPTIONS.