I am over the age of 18 and desire Brandell Hecker R.N to perform the elective cosmetic pigmentation procedure understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure(s).
I also understand that the cosmetic pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. Laser treatments may also compromise the cosmetic pigmentation procedure application. I fully understand as with all such procedures that this is not a science but rather an art and that anything that can go wrong may go wrong. I request the cosmetic pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s).
For the purpose of documentation, I also consent to the taking of before, during and after photographs/videos of said procedure(s) which become the technician's sole property and may or may not be used for whatever purpose deemed necessary including using pictures for social media and advertising publications. IF YOU DO NOT WANT YOUR PICTURES POSTED ONLINE PLEASE ADVISE YOUR TECHNICIAN. Understanding the cosmetic pigmentation procedure, the permanency of the procedure, the possible consequences of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize Brandell Hecker, RN to perform the cosmetic pigmentation procedure(s).
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic pigmentation procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. January 19, 2021
Do you agree to the fees discussed?
I fully understand that a cancelation fee of 50% of the price of the procedure will be charged or deducted off the deposit in the event of cancellation of procedure with less then 48 hour notice. The entire staff is dedicated to client satisfaction. We employ a no refund policy and I am aware of this.
I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $100-$300 charge depending upon the amount of work needed.
There is a possibility of an allergic reaction of pigments. A patch test if advisable however it does not ensure a client will not have an allergic reaction. Patch test: You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results, if desired.
If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigment contents are: iron oxide, lakes, alcohol, Glycerine and distilled/sterile water) I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure.
I have read the above and had explained to me and fully understand this consent and procedure form: That the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following the cosmetic pigmentation procedure which is to be performed at my request according to this consent and procedure form. I also understand that this procedure is semi-permanent.
I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results.