Loading...

Re-Consent Form For Touch Up Visits

I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed.

I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them. 

Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color. 

I understand that the color selection and color results in all procedures are not an exact science. 

I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restalyne and I assume this responsibility. 

I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics. 

If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure. 

I understand that this procedure will fade and this fading can alter the original pigment color and that this determines that it is a time for a touch-up visit. 

I realize this is an elective cosmetic procedure and is not medically necessary. 

It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment. 

I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up. 

I give my consent to Technician to confer with my physicians for medical information required for the safety of my procedures. 

I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner. 

I am aware that if an infection occurs after I have received Permanent Cosmetics to see with my primary physician or an emergency room, immediately

ACCEPTANCE:
I have read and understand these risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and my questions have been answered.

**Please read all questions thoroughly before signing

Today's Date: June 28, 2022

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Are you pregnant or nursing?*
No
Yes
Has your health history changed regarding medication, joint replacement or anything artificial in your body?*
No
Yes

If YES, please specify and also list any new medications and why they were prescribed to you.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!