Consent to application of permanrnt cosmetic procedure

NAME: _______________________________________________ DATE: ________________ DOB: ________________

ADDRESS: _______________________________________________________________________________________

CITY: _________________________________________________ STATE: _______________ ZIP: _________________

HOME PH. ____________________________________________ WORK PH. __________________________________

I, ____________________________, am over the age of 18, am not under the influence of drugs or alcohol, and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing, as well as the specific procedure to be performed, has been explained to me. X_______

PROCEDURE(s): __________________________________________________________________________________

NO. OF VISITS REQUIRED: _____________ COST OF PROCEDURE(s): ________________________________________

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to infection, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science but an art. I request the permanent skin pigmentation procedure(s) and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s). X_______

I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin-altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable. X_______

I have received pre- and post-procedure instructions, and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood-altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips. X_______

I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s). I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done. X_______

I give permission for the use of my photos for the purpose of marketing. My pictures may appear in print or online.

[   ] YES [  ] NO

SIGNATURE: _______________________________________________________ DATE: ________________________

TECHNICIAN: _______________________________________________________ DATE: _______________________

Email: Serey@browsbyserey.com

Ph: 801-232-6790