Consent Form
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Full Name Date of Birth
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Address
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Cell Phone Home Phone Email Address
I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant
or nursing, 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.
I consent to the following procedures:
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Number 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, scarring, inconsistent
color, and spreading, fanning, or fading of pigments.
Corneal abrasions are a rare side effect. 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 procedures and accept the permanence of the procedure as well as the
possible complications and consequences of the said procedures.
There is a possibility of an allergic reaction to pigments. A patch test is advisable
however it does not ensure a client will not have an allergic reaction.
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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.
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.
I understand that the taking of before and after photographs of the said procedures are a
condition of such procedures. I certify I have read the above paragraphs and have had this
consent and procedure permits explained to my understanding. I accept full responsibility
for the decision to have this cosmetic tattoo work done.
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Client’s Printed Name Client’s Signature Date
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