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Birthday
Month
Day
Year
Do you currently have Botox?
Yes
No
Do you currently have diabetes?
Yes
No
Do you currently have lip fillers? (Restylane, Juvederm)
Yes
No
Do you ever have cold sores/fever blisters?
Yes
No
Have you had a Blepharoplasty (eyelid surgery)
Yes
No
Do you have hepatitis? (A,B,C,D)
Yes
No
Brow lift?
Yes
No
Easy bleeding?
Yes
No
Face lift?
Yes
No
Alcoholism?
Yes
No
Eye surgery/injury/corneal abrasion?
Yes
No
Abnormal heart condition?
Yes
No
Do you currently wear contact lenses?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
So you use accutane or acne treatment?
Yes
No
Are you taking blood thinners such as: Aspirin, ibuprofen, alcohol, Coumadin, etc?
Yes
No
Do you use any skin care products that contain Retin-A, glycolic acid, alpha hydroxy?
Yes
No

Possible risks, hazards, or complications


Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. Lip procedures are more likely to involve some pain.


Infection: infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See ‘aftercare’ sheet for instructions on care which will be handed to you at your appointment.


Uneven pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow up appointment will likely correct any uneven appearance.


Asymmetry: every effort will be made to avoid asymmetry, but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness.


Excessive swelling or bruising: some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears within 1 to 5 days. Some people don’t bruise or swell at all.


Eye exposure: there is a small risk of eye injury when an eyeliner procedure is performed to avoid corneal abrasions, Celluvisc, a thick eyedrop is used to protect the eye prior to the procedure eye drops are used to cleanse and flush the eye after the procedure is complete.


Anesthesia: topical anesthetics are used to numb the area to be tattooed like a prilocaine, benzocaine, tetracaine, and epinephrine in a cream or gel form are typically used if you are allergic to any of these please inform me now.


MRI: because pigments used in a permanent cosmetic procedure contained in their oxide. A low level magnet may be required. If you need to be scanned by an MRI machine, you must inform your technician of any tattoos or permanent cosmetics.

Fever blisters (Lip blushing) : if you are prone to cold, sores or fever blisters (herpes simplex) there is a high probability that you will get them. It is advised that you call your doctor for a prescription antiviral to help prevent this from occurring.


Allergic reaction: there is a small possibility of an allergic reaction. You may take 5 to 7 day patch test to determine this. (Please initial to waive or take below)


THE ALTERNATIVE TO THESE POSSIBILITIES IS TO USE COSMETICS AND NOT UNDERGO THE PERMANENT COSMETICS PROCEDURE.


Patch test?
Waive
Take

I certified I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure and 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 Tanya as my permanent cosmetics technician to perform on my body, the following procedures.

Date
Month
Day
Year

This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetic application. If you have any questions, please don’t hesitate to ask.


Although permanent cosmetic tattooing is effective in most cases no guarantee can be made that a specific client will benefit from the procedure.


This is the process of inserting pigment into the dermal layer of skin and is a form of tattooing.


All instruments that enter the skin or come in contact with bodily fluids are sealed and sterilized before use and disposed of after use cross contamination guidelines are strictly adhered to.


Generally the results are excellent however, a perfect result is not realistic expectation it is usual to expect a touchup after the healing is completed.


Initially, the color will appear much more vibrant or darker compared to the end result. Usually within 57 days, the color will fade at 10 to 50% soften and look more natural. The pigment is permanent but will fade somewhat overtime and will likely need to be touched up through the years.

Photography and videography release consent

Enhanced LLC’s insurance company requires “before” and “after” photos videos, be taken and kept on file.


We would like your permission to use these photos, videos for advertising. For example, and portfolios, online and in print ads, etc. Your consent is necessary regarding this. Please indicate with your signature if you would like your photos, video used or not used in advertising.

My photos/videos can be used in advertising
Yes
No
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