Consent form

PRETTY IN INK
CONFIDENTIAL CONSENT AND RELEASE AGREEMENT
PLEASE PRINT
Name/Releasor: ________________________________ Today’s Date: _________ D.O.B.: __________ Home Phone: ____________________
Address: __________________________________________________City, State, Zip: _______________________________________________
Cell Phone Number: _________________________________________ Email: ______________________________________________________
MEDICAL HISTORY
Please circle “yes” or “no” as applicable :
Diabetes ……………………… Eye Disease…………………… Yes No
Do you use Acutane?………………. Yes No
Epilepsy……………. ………… Yes No
HIV…………………………… Yes No
Are you at least 18 years old?…….…. Yes No
Keloid Formation……………. Yes No
Autoimmune Disease………… Yes No
Do you have any tattoos?……. Yes No
Hemophiliac…………………. Yes No
Blood Disease…………………. Yes No
Have you had plastic surgery?………. Yes No
Active Skin Disease…………. Yes No
Pregnant or Nursing…………. Yes No
Do you plan to have plastic surgery?… Yes No
Hepatitis……………………… Yes No
Alopecia………………………. Yes No
Do you wear contact lenses?….….
Cancer………………………… Yes No
Alcohol consumption…….… Yes No
Do you use glycolic acids?. Yes No
Heart Condition……………… Yes No
High or Low Blood Pressure… Yes No
Do you use Retin-A?…………………
Genital Herpes…………….… Yes No
Pacemaker…………………… Yes No
Do you smoke?………………………
Glaucoma……………………. Yes No
Cold Sores……………………. Yes No
Do you like to tan?: …………… Yes No
If there is any other medical history not mentioned above, please list: ____________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Are you currently under a doctor’s care? Yes No Explain: _________________________________________________________________________________
Are you taking any medications? Yes No Please List: _________________________________________________________________________________
Do you have any allergies? Yes No Explain: ________________________________________________________________________________
Have you ever had an adverse reaction to cosmetics? Yes No Explain: _________________________________________________________________________
This Agreement is entered into by the above named Releasor and PRETTY IN INK, hereinafter know as the Releasee:
1. The Releasor fully and voluntarily consents to have the Releasee perform cosmetic tattoo procedure(s) and is fully aware and informed of
any and all inherent risks, dangers and complications that may occur as a result of the procedure(s), which may include, but are not limited to:
scarring, infections, allergic reactions, corneal abrasions, herpes (cold sore) outbreaks, eye injury, swelling, pain, bruising, minor bleeding,
redness, soreness, hyper-pigmentation, etc. The Releasor understands that the cosmetic tattoo procedure is an art, not an exact science, and
that the tattoo(s) may not appear exactly as the Releasor anticipates.
2. The Releasor acknowledges that all questions have been answered and all known risks, dangers and complications have been explained and
hereby agrees to forever release the Releasee from all claims, damages or liabilities that may result from the cosmetics tattoos as described in
this Agreement, including costs of medical care that may arise from the procedure, including post-procedure care. The Releasor acknowledges
that the Releasee has made no claims, representations or guarantees, other than as expressly stated herein.
3. The Releasor agrees to accept full responsibility for each and every procedure that the Releasor asks the Releasee to perform, including, but
not limited to: Eyebrows, Eyeliner, Lash Line Enhancement, Lips, Beauty Marks, Scar Camouflage and Areola Restoration. The Releasor
understands that it is unlikely, if not impossible, that the Releasee will be able to make any of the procedures perfectly symmetrical. In other
words, for example, the Releasee cannot expect one eyeliner or eyebrow to look exactly like its “sister.” The Releasor acknowledges that he/she
has received, read, and discussed with the Releasee instructions regarding post-procedure care, Releasor understands said instructions and
agrees to follow such instructions to help prevent secondary infection.
4. The Releasor CONSENTS TO / WAIVES (circle one) a patch test prior to the procedure to assess the likelihood that the Releasor will have
an allergic reaction to the pigments to be used by the Releasee.
5. The Releasor acknowledges that cosmetic pigments can heal inconsistently, spread or fan, and can and will fade. It is the Releasor’s
responsibility to schedule a touch-up to be done three to six weeks after the initial procedure. This touch up will be done at no cost to the
Releasor if scheduled within said time period. After six weeks, the Releasor agrees to pay a service fee for any and all future touch-ups.
6. The Releasor understands that the cosmetic tattoo(s) will appear thicker and darker immediately after the procedure than it will one week
later. Within three to four days after the procedure, the outer layer of pigment will begin to slough off and the tattoo will then appear lighter,
softer and less defined.
7. The Releasor understands that: (i) he/she should not donate blood for one year following a tattoo procedure; (ii) tattoo removal can be costly
and painful; (iii) he/she should advise medical personnel or professional estheticians of the existence of the cosmetic tattoo if a chemical peel,
MRI, or plastic surgery is to be performed near or over the cosmetic tattoo; (iv) he/she should obtain a prescription for Zovirax, Valtrex or
some other prescription cold sore medication to prevent the onset or spread of cold sores during a lip procedure; (v) sun, chlorine water,
glycolic acids and microdermabrasion may fade or otherwise effect the color of the pigments; (vi) anything applied to the procedure area
within two (2) weeks after the procedure may cause an infection; and (vii) he/she should not wear contact lenses during an eyeliner/eyelash line
enhancement procedure.
I hereby authorize PRETTY IN INK to perform the following procedures:
______ Eyebrows _____ Upper Eyeliner/Eyelash Line/Wet Line Enhancement ______ Lower Eyeliner/Eyelash Line/Wet Line Enhancement
______ Lip Liner ______ Lip Fill ______ Lip Augmentation ______Beauty Mark ______ Scar Camouflage ______ Areola Restoration
Please read and initial:
______I consent to the use of my before and after photographs for advertising purposes.
______I have received, read, and understand the aftercare instructions.
I certify that I have read and fully understand this Confidential Consent and Release Agreement, and that I accept full responsibility for any
complications which may arise during or after the cosmetic tattoo procedure that the Releasee is to perform at my request. I also understand
and affirm that the Releasee has not provided any warranty or guarantee regarding the outcome of the procedure. (If the Releasor is under
the age of 18, a Parent or Guardian must sign on behalf of the Releasor.)
Signature of Releasor: ___________________________________________________ Date: _____________________________
Signature of Releasee: ___________________________________________________ Date: _____________________________
FOR OFFICE USE ONLY
Procedure Performed:
_____ Eyebrows ______Upper Eyeliner/Lash Line/Wet Line Enhancement ______Lower Eyeliner/Lash Line/Wet Line Enhancement
______Lip Liner ______ Lip Fill _____ Beauty Mark _____ Scar Camouflage ______ Right Areola _____ Left Areola
Color Used: ____________________________________ for: _________________________________ Date: ________________
Brand: ________________________________________ Lot#: ____________________________Exp. Date: ________________
Color Used: ____________________________________ for: _________________________________ Date: ________________
Brand: ________________________________________ Lot#: ____________________________Exp. Date: ________________
Color Used: ____________________________________ for: _________________________________ Date: ________________
Brand: ________________________________________ Lot#: ____________________________Exp. Date: ________________
Anesthetic: ____________________________________ Lot#: ____________________________ Exp. Date: ________________
Anesthetic: ____________________________________ Lot#: ____________________________ Exp. Date: ________________
Anesthetic: ____________________________________ Lot#: ____________________________ Exp. Date: ________________
Location where procedure(s) performed: ________________________________________________________________________
Comments: _________________________________________________________________________________________________

Source: http://www.prettyininkny.com/forms/CONSENT_FORM.pdf