The nature and method of the proposed cosmetic tattoo procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complication during and following its performance. I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure may occur, however, if properly cared for, is rare.
I also acknowledge that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the fact and matters set below, and I agree as follows:
Are your pregnant, nursing or trying (IVF) to get pregnant? (If you circle, I don't know, services will not be performed)
I have read and fully understand the contents of each paragraph above. I acknowledge this is a legal & binding contract and that I have received no warranties or guarantees with respect to the benefits to be realized from or consequences of, the aforementioned procedures(s). I further acknowledge that at the time of the signing this consent to this procedures(s), I was of sound mind and capable of making independent decisions for myself.
Confidential Medical Profile
To avoid unforeseen complications, please answer the following questions:
Are your over the age of 18?
Have you consumed alcohol today?
Have you had any aspirin or blood thinning products within the last 7 days?
Do have any history cold sores, herpes, or fever blister?
Any mood-altering drugs within the last 8 hours? (i.e Wellbutrin,Xanax, Prozac)
Are you sensitive to Latex?
Have you had a chemical or laser peel within the last 7 days?
Do you have a problem with healing?
Previous problems with tattoos or has your physician advised you not to have a tattoo at this time?
Are currently undergoing radiation or chemotherpy
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)
Do you wear contact lenses?
Are you allergic to any metal?(e.g. Can only wear 14Kgold)
Have you ever had any cosmetic tattoo procedures done prior to us? Area? When?
Medications, including immunosuppressants such as anti-inflammatory or steroids?
Did you have caffeine products today?
Are you allergic to topical antibiotic numbing creams or desensitizers
Is there any history of skin diseases or remarkable skin sensitivites?
Are you taking any vitamins
Are you pregnant, trying or nursing?
Are you required to take antibiotics during dental or invasive medical procedures?
Do you have drug allergies? If yes list space provided at the end of the form.
How many times/week do you?
Practitioner makes no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible reasons restricting you from receiving a tattoo, you must approve of the design and color before the application of your permanent makeup.
Do you, or have had, any of the following:
Please explain any checked question, list any other medical conditions or allergies, and list your medications
Client Consent to be Photographed