Client Consent Form

Permanent Cosmetics

Type of Procedure

CONSENT AND RELEASE AGREEMENT FOR SEMI-PERMANENT COSMETICS

This form provides information to assist in making an informed decision of whether or not to undergo a semi-permanent cosmetics application. If you have 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 depositing pigment into the top dermal layer of the skin and is a form of tattooing.

All instruments that enter the skin or come in contact with body 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 a realistic expectation after an initial application. It is usual to expect a touch-up after the healing is completed.

Initially the color will appear much more vibrant or darker compared to the end result. Usually within 5-7 days your brows will lose 25% in thickness and the color will lighten 40-50%, soften and look more natural. The pigment will fade somewhat over time and will likely need to be touched-up through the years. Second touched-up may or may not cover on the 1st procedure. It is depending on what is included in the deal, please remember to check us before proceed.

Client medical History

You are not a candidate for micro pigmentation if any of the following apply to you:

Diabetes
Pregnancy
Nursing
Lupus
Hepatitis (A,B,C,D)
AIDS
Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis, Pink Eye, Sun Burn, Severe Acne

Herpes
Active Vitiligo
Severe Rosacea
Blood Disorders: Sickle Cell, Hemophilia
Keloid Formation
Mental Disorder
Accutane (must be 0_ for 6 months)
Steroids (must be 0_ for 6 months)
Retinol/Retin-A (stop using 7 days prior)

Do the medical list above apply to you in any way?**

Yes

Restrictions:

Injections (Botox, Radiesse, JuvaDerm, Voluma, etc.) must be done 2 weeks before or 2 weeks after procedure.
Chemical peels and laser treatments may not be done within 60 days before or after procedure.
Sunburned or Suntanned skin is damaged skin and therefore will cause excessive bleeding.
We CANNOT work on sunburned or suntanned skin.
You cannot expose the area to the sun for 30 days before or after procedure.
Do not schedule this procedure within one week prior to a water vacation and expose to sun for long period.
Stay out of steam rooms, saunas, hot yoga, swimming pool, etc. for one week following procedure.

Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift?**

Yes

Eye surgery/ injury/lasik eye surgery within 1 year?**

Yes

Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect.**

Allergies to metals, food, latex, antibiotics.**

Yes

Currently on any blood-thinning prescription drugs.**

Yes

If yes, when?

Special requests, concerns or remarks for technician:

Photo Permission

I grant permission to TN-Beauty, Thunyatorn LLC, Thai Serenity Spa to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist.**

Yes

STATEMENT OF CONSENT AND RECITALS:
PLEASE READ AND CHECK ALL LINES

I acknowledge I am age 18 or older.

I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, poor color retention and hyper-pigmentation.

I accept the responsibility of explaining to you my desire for specific colors, shape, and position for any procedure done today.

I understand that after my service, there will be no refunds. No exceptions.

All complimentary followup sessions that are must be done 6-9 weeks from initial session. Failure to make this appointment will incur its corresponding fee.

I understand that implanted pigment color can slightly change in color or in shape and fade over time due to circumstances beyond my artist control. I will need to maintain the color with future applications at my own expense.

I acknowledge that this procedure may alter my appearance and that no representations have been made to me as to remove my permanent makeup. To my knowledge I do not have a physical, mental, medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have permanent makeup.

I acknowledge it is not reasonably possible for my technician to determine whether I might have an ALLERGIC reaction to the pigments, anesthetic or ointment used in this process. I agree to forego a patch test and accept the risk that such reaction is possible.

Notice that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.

The staff at TN-Beauty, Thai Serenity Spa and Thunyatorn, do not practice medicine, does not accept health insurance, and have made no representation to the contrary.
The information provided on this form is accurate and complete to the best of my knowledge, and that TN-Beauty, Thai Serenity Spa and Thunyatorn are not responsible for complications or problems arising from any incorrect or omitted information. I will contact my doctor immediately, if I experience abnormal pain, discomfort, infection due to lack of proper after-care or health related issue.
Some individuals will have complications related to semi-permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold Thunyatorn and its employees and contractors harmless for same.
I have read all the Precare guidelines and acknowledge that Aftercare instructions are available on www.TN-Beauty.com. I agree to follow them to the best of my ability. I agree that any touch up work needed, due to my negligence will be done at my own expense.

I certify that I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered.

By signing below, I acknowledge, understand and agree with all the items on this form.**

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