Consent for Cosmetic Tattooing Treatment Please enable JavaScript in your browser to complete this form.Name *FirstLastDate TodayDate of BirthAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWho referred you?Eyebrow microblading/cosmetic tattooing is the process of implanting pigment into the skin to create soft, feathery hair like strokes using tiny, sterile and disposable needles. This helps to fill in gaps, elongates the brow due to thinning, creates brows or adds density. We use pigment that can last anywhere from 1-3 years, depending on lifestyle or skin. (ie sun exposure or AHA usage) we use this to account for changes in the face. We custom mix the color depending on your eyebrow color and skin tone and use techniques to measure your eyebrow bone structure, facial features and natural hair growth, to create a shape just for you. I am over the age of 18, am not under the influence of alcohol or drugs and the general nature of the cosmetic tattooing procedure to be performed has been explained to me *YesAre you currently under the care of a physician? *YesNoIf so, why?Do you take antibiotics when going to the dentist? *YesNoIf so, why?Do you suffer from any of the following?AllergiesDiabetesEpilepsyHepatitisHeart ProblemsHemophiliaScarring/KeloidsSkin ConditionsIf so, please explain.Are you presently taking any medications that thin the blood?YesNoAny other medications?Are you pregnant or nursing?YesNoDo you wear contact lenses?YesNoI have been informed of the nature, risks and possible complications and consequences of permanent skin pigmentation. I understand that permanent skin pigmentation can carry known and unknown complications including but not limited to: infection, allergic reaction, scarring, inconsistent color, spreading, fanning or fading of pigments. I understand that the color of the pigment may modify slightly due to the tone and color of my skin. *YesI understand that if I have any skin treatments, involving skin thinners, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetic treatment. *YesI have received post procedure treatment instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances at a successful procedure. *YesI understand that taking before and after photographs of the procedure is a condition of it, if you do not want me to use them for marketing and/or instagram please indicate:: YesNoSignature Clear Signature DateNameSubmit
