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CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURES, MEDICAL HISTORY AND RELEASE OF LIABILITY

AGE OF CLIENT VERIFIED BY INKCHARM PRACTITIONER WITH CLIENT'S GOVERNMENT-ISSUED IDENTIFICATION CARD

*If upload is not feasible via site, please bring ID at time of appointment.

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A  form of government-issued ID MUST be provided.  If you cannot/do not want to upload the ID above, please provide the type of ID and its corresponding ID number in the "additional info" window located at the end of this form and bring that ID with you at the time of your appointment for confirmation. 

I,

, am of sound mind and body and over the age of 18.  I am not under the 

influence of drugs or alcohol.

The general nature of cosmetic tattoos and the specific procedure(s) to be preformed have been explained to me.  I wish to receive the permanent cosmetic procedure(s) referenced below. 

1.

I understand permanent/semi-permanent makeup is a form of tattoo that requires implantation of pigment into my skin using a needle.

2.

I understand that InkCharm has a 72-hour cancellation policy and a non-refundable deposit for appointments marked no show or same day canceled.  If I need to reschedule outside of

72 hours for my initial or complimentary check-up appointment, I must contact InkCharm immediately.

3.

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation.  I understand the permanent skin pigmentation procedure comes

with risk of known and unknown complications and consequences 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 contact lenses too soon after any eyeliner procedure. 

4.

I have been advised 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.  I have been advised that tattoos are permanent, and no claims about the possibility of reversing this permanent change to my body has been made or implied.   This Notice is required to be provided to me by the California Health and Safety Code, and I acknowledge receipt of this notice. 

5.

I understand the actual color of the pigment, once implanted, may vary from person to person due to the tone and color of the a tattoo recipient's skin.  I also understand the tattoo process

is not an exact science, but an art. I still wish to receive the procedure(s) referenced above and accept the permanence of the procedure(s) as well as the possible complications and consequences of said procedure(s).

6.

I understand there is a possibility of an allergic reaction to pigments.  A patch test may be effective to determine if I will have an allergic reaction.  I WAIVE the patch test and release

InkCharm and its technician/practitioner from liability if I develop an allergic reaction to the pigment.

7.

I understand 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.

8.

I have received pre-and post-procedure instructions.  I will strictly adhere to these instructions.  I understand that my failure to do so may jeopardize my changes for a

successful procedure and/or increase the risk of complications.  I will disclose any medication for depression or other mood-altering drugs.  If I have ever had cold sores, I will consult  with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedures on or around my lips. 

9.

I understand it is my responsibility to disclose any problems I or my doctor believe may occur for any reason, including but not limited to reasons related to allergies, illness and

medications - including aspirin and/or other medications that cause the blood to thin.

10.

I understand InkCharm has made no warranties or guaranties regarding its procedures.  I further understand that cosmetic tattooing will fade with time and require touch-ups.

11.

 

I understand the taking of before-and-after photographs of the procedure(s) I receive are a condition of receiving the procedure(s).

12.

 

I understand that all procedures, including touch-ups are nonrefundable. No exceptions.

13.

 

Each of the paragraphs above have been explained to me to my satisfaction, and I accept full responsibility for my decision to receive my procedure(s).

CONFIDENTIAL MEDICAL HISTORY

1.

Have you had Botox/Dysport or any fillers recently?
Are you currently using, or have used, any products containg Retin-A or Hyaluronic Adic (or similar ingredient)?

2.

3.

Do you use any medications that might affect the healing of the procedure(s) you wish to receive?

4.

Do you have any allergies, including antibiotics?

5.

Do you take any blood thinners, including aspirin or ibuprofen?

6.

Are you allergic to latex?

7.

Are you pregnant?

8.

Have you consumed alcohol today?

9.

Have you consumed caffeine today?

10.

Do you have any of the following conditions?

11.

Do you have a history of medication use or currently using medication, including prescribed antibiotics prior to dental or surgical procedures?

12.

Any other conditions?

All information gathered from the client that is personal medical information and that is subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA) or similar state laws shall be maintained or disposed of in compliance with those provisions. 

I certify that this Consent, Medical History and Release from Liability Agreement was completed by me and that all entries are true and complete to the best of my knowledge. 

I also certify that I have been fully informed of the risks of permanent/semi-permanent makeup/tattoo procedures, including but not limited to: infection, scarring, difficulties in detecting melanoma and allergic reactions to pigment, latex gloves and other products. 

Having been informed of the potential risks associated with permanent/semi-permanent makeup/tattoos, I still wish to proceed and assume any and all risks that may arise from the procedures(s). 

I certify that I take full responsibility, release InkCharm and its practitioners from all liability and waive any claims against InkCharm and its technicians to the fullest extent permitted by law, for any direct and/or indirect damages which may result from the procedure(s) referenced herein. 

Thanks for submitting!

Additonal Info here
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