Client Informed Consent For Permanent Makeup Enhancement My procedure today is: Microblading Ombre/Powder Brow Combo Brows First Name Last Name Full Address Email Phone Number DOB Age Sex M F Drivers license or ID # History of MRSA Yes No History of keloids Yes No History of alcoholism Yes No Abnormal heart condition Tumors, growths, cysts Yes No Pregnant or breast feeding now Yes No Do you give blood Yes No Do you smoke Yes No Oily skin Yes No Current meds Difficulty numbing with dental work Yes No Prior to dental procedures, do you receive antibiotic therapy Yes No Surgeries in the past year Cancer Yes No If yes, year: Chemo or radiation in the last year Yes No Accutane or acne treatmeant Yes No If yes, date: Tan by booth or sun Yes No If yes, date of last time: Brow or last tinting Yes No If yes, date: Forehead or brow lift: Yes No If yes, date: Face lift Yes No If yes, date: Taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin, fish oil etc. Do you have an MRI scan scheduled in the next 3 months? Yes No Do you have a Laser or IPL scheduled in the next 3 months? Yes No Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl? Yes No Allergic reaction to any of the following medications: Lidocaine, Tetracaine, Epinephrine,Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, etc. Allergic reaction to any of the following: antibiotic ointments, metals, latex, rubber, hairdye, paints, nuts,medication, drugs, foods, crayons, glycerine? How many times per week do you work out or go in the sauna (if any) How often are you in the sun for more than 30 minutes? (i.e tanning, outdoor activities, running,gardening etc.) Do you get facials, peels, microdermabrasions etc? If so, how often? How often do you go swimming? I hereby authorize Stephanie Hibbard to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises in the course of the procedure(s), I further request and authorize PeerlessPmu to use its full judgment and do whatever is deemed advisable and necessary in the circumstances without any liability to PeerlessPmu. I understand that semi-permanent and permanent cosmetic enhancement is an advanced form of tattoo. I accept full responsibility for determining the color, shape, and position of the enhancement as mutually agreed upon during the course of my consultation. I understand that a commercially reasonable effort will be made to avoid unevenness, but some bone structure, facial deformity or birthmarks, or muscle movement does not call for perfect symmetry. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs. I understand that employee(s), practitioner, or any personnel from PeerlessPmu are not licensed physicians or medical doctors and was made aware to seek a licensed physician or medical doctor’s opinion if needed. I am aware that a sensitivity reaction to anesthetics can occur and accept all responsibility if allergic response occurs. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over the course of 1 to 2 years. Even though the color has faded, the pigment will stay in the skin indefinitely and may leave a light residue of color on the skin. I understand that dyes, inks, and pigments are not approved by the Food and Drug Administration (“FDA”), and the health effects are not known. I accept that the highest standards of hygiene are met, and that sterile disposable needles are used for each individual client, procedure, and visit. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results and that 100% success cannot be guaranteed. I understand that this is why I may need to return for a touch-up procedure or additional touch-ups thereafter. I understand that the initial touchup procedure, if required, will be performed 6 weeks to 3 months after the initial procedure and that after the 3 month period, I will be charged an additional fee for any procedures or services. I will book an appointment when it is convenient for both parties. I understand that all services are non-transferrable and non-refundable (full or partial refund). I understand that semi-permanent cosmetic enhancement is an invasive procedure, and the infusion process can be uncomfortable or sometimes painful depending on my sensitivity. I am aware that the result of the procedure is determined by the following: *Medication for compromised immune system *Skin characteristics - i.e. dry/oily/sun-damage *Poor diet *Natural skin undertones *Post-procedure care treatment *Alcohol intake and smoking lifestyle *General stress *Sun exposure I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will most likely subside within 1 to 2 days dependent on lifestyle or any factors listed above. In some cases, bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration, and exposure to the sun should be limited for up to 2 weeks following the infusion process. I understand that immediately after the procedure, the enhancement may be 40% to 60% darker than the desired result and may take between 4 to 10 days to lighten. I understand that the true color will be visible approximately 1 month after each application, and that the color may vary according to skin tones, skin type, age, and skin conditions. I acknowledge that some skins accept color more readily than others, and no guarantee of an exact effect or color can be given. I acknowledge that the proposed procedure(s) involve inherent and unforeseeable risks in the procedure and have possibilities of complications during and/or following the procedure(s) such as: infection, misplaced pigment, poor color retention and hyper-pigmentation. I understand that there are few effective methods for pigment removal. Li-Ft and laser removal has proven successful, however is a process, which may take some time. I have been quoted the cost of today’s procedure and understand that future touch-up rates and/or policies are subject to change. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner, employee, or contractor of PeerlessPmu I understand that infection and possible scarring can occur if I do not adhere to the said instructions. I understand that PeerlessPmu can release me as a client at any given time with or without a reason. I understand that Retin A, Renova, Alpha Hydroxy, Glycolic Acids, Aloe, and Vitamin E products must not be used on the treated areas or forehead area during healing. To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s). I give my consent for before and after pictures to be used for marketing. I understand that the Chatham County Board of Health makes no guarantee the will be no injury due to the aforementioned procedure being performed. Furthermore, Chatham County Board of Health assumes no liability for any injury which may occur. Acceptance By accepting below I agree that all the above information is true and accurate to the best of my knowledge. Acceptance Date I declare that I give my full consent to the placement of tattoo carried out by the aforementioned practitioner PeerlessPmu confirm that potential complications, e.g. infection and swelling, for the procedure undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me, and I agree that it is my responsibility to read this and follow the instructions on it until the area treated has healed. I certify that I have read or have had read to me the contents of this form. I understand the inherent and unforeseeable risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize PeerlessPmu to perform on my body the procedure desired today. I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e. 18 years old for tattoos), and that I am not currently under the influence of alcohol or drugs. I CERTIFY THAT I HAVE READ, HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL. By accepting, the client agrees to the terms listed above. Clients full name Date Send