Informed Consent- Permanent Makeup

Informed Consent- Permanent Makeup

Kristen Form Preview
  • Informed Consent for Permanent Makeup

    And pertinent medical questionaire
  •  -

    The State of Florida prohibits tattooing anyone under the age of 18 without a form from the Health Department notarized and signed by BOTH parents or legal guardians. Anyone who appears under the age of 18 must supply a license or student ID with birth date to be copied for the file.

    I, the undersigned and the person named above, hereinafter referred to as CUSTOMER, have been duly informed by KRISTEN ESGATE of BEAUTY BY KITTEN, hereinafter referred to as OPERATOR, of the nature, risk and possible complication and consequences of the permanent make-up procedure for which I have contracted OPERATOR to do. I understand that this procedure is designed to enhance my appearance, and I consent to said treatment, which shall be performed by, or under the direction of OPERATOR. I further understand that this cosmetic procedure, using the permanent make-up process/tattoo, is a permanent cosmetic and cannot be removed or easily changed as other cosmetics and agree to release OPERATOR from all manner of liabilities, claims, actions, and demands in law, or in equity, which I or my heirs might now or hereafter consider by reason of complying with my request of a tattoo procedure. I fully understand that any employee of OPERATOR, when performing a permanent make-up procedure, does not act in the capacity as a medical professional. The suggestions made by any employee or agent of the OPERATOR are just suggestions. They are not to be construed as, or substituted for advice from a medical professional. I understand that the permanent makeup procedure will be performed using appropriate techniques, instruments, and pigments. I also understand that infections can occur due to lack of proper hygiene and/or pigment sensitivities. I have been advised and I fully understand that improper skin care may lead to an infection of the treated area. OPERATOR has given me proper written and verbal skin care instructions. To ensure proper healing of the treated area, I agree to follow the written and verbal aftercare instructions that will be provided, until healing is complete. I understand that the treated area may take up to two weeks to heal properly. I acknowledge that should my skin become infected due to improper skin care, I will hold OPERATOR harmless. The permanent make-up which I have contracted for is a lasting impression that will gradually fade with age and with proper skin care between 1 & 10 years. I am, however, fully informed and aware that the work may fade sooner as a result of age, skin care, and prolonged exposure to the sun or to chlorinated and/or salt water. Should the work fade, I will not hold the OPERATOR liable for such consequence.

    I certify that the following medical information provided is accurate, true, and current to the best of my knowledge. I am informed and understand that not disclosing accurate and current pertinent medical information may directly affect the healing process and results of any permanent makeup and tattooing procedures. I also am informed and understand that not disclosing medical conditions can potentially placed the OPERATOR and associated staff at risk.

    I am informed and understand that if my skin is excessively oily, there is a chance that the work may fade sooner. I Acknowledge that I have informed OPERATOR of my skin condition, and if my skin is excessively oily, and I still consent to this procedure, I will hold OPERATOR harmless in the event such fading occurs.

    I am informed and understand that the work will not in any way contribute to nor itself induce a loosening of the skin. I am informed and agree that OPERATOR shall not be liable in the event such condition occurs. I understand that my photos may be used for educational or advertising purposes and give up all rights to these photos. I will let the OPERATOR make any and all decisions regarding photos taken of myself by the OPERATOR and understand I will receive no compensation regarding these photos.

    I have read this release form and confirm that all the information I have given on this document and the Customer Health History form is correct and to follow the General After Care Instructions. I understand that this is a release form and I agree to be legally bound by it.

  •  /  /
    Pick a Date
  • Clear
  • Clear
  •  -  -
    Pick a Date
Now create your own JotForm - It's free! Create your own JotForm