CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETICS – XO Beauty Spa

Client Medical History Form

Today's Date

Name

First

Last

Please take a photo of your ID, for CLIENT RECORD (Front-side). This is required by the "25 Tex. Admin. Code § 229.406"

Click or drag a file to this area to upload.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Emergency Contact

First

Last

Phone

Do you presently have or previously had any of the following: Check If Yes! or Skip!

Chemical Peel?

If yes, when was your last treatment?

Taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin, etc.

If yes, please list.

Allergic reaction to any medications such as Lidocaine, Benzyl alcohol, Vitamin E Acetate, etc.

If yes, please list.

Allergies to metal, food, etc.

If yes, please list.

Any diseases or disorders not listed?

If yes, please list.

Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl? Please list medications or vitamins you are presently taking:

If yes, please list.

I agree that all the above information is true and accurate to the best of my knowledge.

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CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETICS

This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetics application. If you have questions, please don’t hesitate to ask. Although permanent cosmetic tattooing is affective in most cases, no guarantee 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 and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sealed a sterilized before use and disposed of after use. Cross contamination guidelines are stickily adhered to. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed. Initially the color will appear much more vibrant or darker compared to the end result. Usually within 57 days the color will fade 10-50%, soften and look more natural. The pigment is permanent but will fade somewhat over time and will likely need to be touched-up through the years.

PHOTOGRAPHY AND VIDEOGRAPHY RELEASE CONSENT

Our insurance company requires “Before” and “After” photos/videos be taken and kept on file. We would like your permission to use these photos/videos for advertising. For example, in portfolios, online and in print adds, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos/video used or not used in advertising.

Checkboxes

YES, feel free to use them

Signature

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Signature for CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETICS & PHOTOGRAPHY AND VIDEOGRAPHY RELEASE CONSENT

POSSIBLE RISKS, HAZARDS OR COMPLICATIONS

Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others

Infection:

Infection is very unusual. The areas treated must be kept clean an only freshly cleaned hands should touch the areas. See “After Care” sheet for instructions on care.

Uneven Pigmentation:

This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance

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 or Bruising:

Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-5 days. Some people don’t bruise or swell at all

Eye Exposure:

There is small risk of eye injury when an eyeliner procedure is performed. To avoid corneal abrasion, Celluvisc, a thick eye drop is used to protect the eye prior to the procedure. Eye drops are used to cleanse and flush the eye after the procedure is complete.

Anesthesia:

Topical anesthetics are used to numb 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 me now flush the eye after the procedure is complete.

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 technician of any tattoos or permanent cosmetics

Fever Blisters:

If you are prone to cold sores or fever blisters, (herpes simplex), there is a high probability that you will get them. It is advised that you call your doctor for a prescription antiviral to help prevent this form occurring.

The alternative to these possibilities is to use cosmetics and not undergo the Permanent Cosmetics procedure. Consent and release for procedures performed:

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STATEMENT OF CONSENT AND RECITALS. PLEASE READ AND CHECK ALL LINES.

Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions I will call or email you.

Section 1

I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.

Section 2

I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.

Section 3

I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI.

Section 4

I accept the responsibility for explain to you my desire for specific colors shape, and position for any procedure done today.

Section 5

I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch up session within 60 days.

Section 6

I acknowledge that the proposed procedure(s) involved risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infections, misplaced pigment, poor color retention and hyperpigmentation.

Section 7

I accept full responsibility for the decision to have this cosmetic tattoo work done.

I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize_______ , as my permanent cosmetics technician to perform on my body the following procedures.

Please enter your PMU technician name.

I have read, understand and agree to the above STATEMENT OF CONSENT AND RECITALS.

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AFTERCARE

After care is very important for producing a beautiful and lasting result.

*Keep the area clean by washing with freshly washed hands and a mild soap. Do not use a washcloth or sponge to remove soap. Simply splash with water. Do not use cleansing creams, acne cleansers or astringents. Use a mild, natural soap. ** Apply the aftercare balm with freshly washed hands or a Q-tip. If the balm is too stiff to use simply warm it up in a glass of warm water or on your finger. Use the balm very sparingly. Too little is better than too much. Blot off excess with a clean tissue. Never touch the procedure area without washing your hands immediately before. *** Do not scrub, rub or pick at the epithelial crust that forms. Allow it to flake off by itself. If it is removed before it is ready the pigment underneath it can be pulled out. **** Do not use any makeup near the procedure area including mascara for eyeliner procedures for at least 3 days. Purchase new mascara and makeup if possible to avoid contamination or bacterial infection. ***** Always use a sun block after the procedure area is healed to protect from sun fading

What’s Normal?

Swelling, itching, scabbing, light bruising and dry tightness.

Swelling, itching, scabbing, light bruising and dry tightness. Ice packs are a nice relief for swelling and bruising. Aftercare calm is nice for scabbing and tightness.

Section 8

Too dark and slightly uneven appearance.

After 2-7 days the darkness will fade and once swelling dissipates unevenness usually disappears. If they are too dark or still a bit uneven after 4 weeks then we will make adjustments during the touch up appointment.

Section 9

Color change or color loss.

As the procedure area heals the color will lighten and sometimes seem to disappear. This can all be addressed during the touch up appointment and is why the touch up necessary. The procedure area has to be completely healed before we can address any concerns. This takes at least four weeks.

Section 10

Needing a touch up months or years later.

A touch up may be needed 1 to 5 years after the initial procedure depending on your skin, medications and sun exposure. We recommend a touch up 30 days after the first session and every few years to keep them looking fresh and beautiful. Touch up sessions after 30 days will be $150 or current touch up rate at time of touch up. Failure to follow after care instructions may result in infections, pigment loss or discoloration.

I have read, understand and agree to the above instructions. I would like to proceed my service today

Clear Signature

Date Signed