leeann royle permanent makeup
Consent and Release Agreement
for Implantation of Pigment for Eyeliner, Eyebrows, Lips, Re-coloration, and Camouflage.
You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. You will be given this document at your scheduled appointment and will be required to sign and initial where indicated and will be kept on file.
Please read the statements below and initial before each one, to indicate that I understand the following completely:
- That no warranty or guarantee has been made to me as a result of this permanent
makeup/camouflage/correction procedure, and that the final result is not guaranteed.
- That there may be risks and hazards related to the performance of this procedure planned for me.
- I realize that there is potential for discomfort during the procedure and during the healing process.
- There is a possibility of bleeding, swelling, bruising, and allergic reactions to the pigment.
- Fever blisters may occur in lip procedures on clients that have the herpes simplex virus and it is my responsibility to obtain an anti-viral prescription from my doctor.
- I understand that Retin-A, Alpha-Hydroxy and Glycolic Acids must not be used on the treated areas, this will cause increased color fading.
- I understand that sun, tanning beds, pools, some skin care products, and medications can affect my permanent makeup.
- That tattooing is considered permanent, however, it may fade with time.
- I will inform all skin care professionals or medical personnel about my permanent makeup, especially if I am scheduled for an MRI.
- That a tattoo can only be removed with a surgical procedure, and that any effective removal is solely my responsibility and may leave permanent scarring or disfigurement.
- That misplacement of dye can occur, under rare circumstances, requiring excision of the
misplaced dye. In rare cases, there may be permanent loss of eyelashes.
- AfterCare Instructions and care kit have been given to me and I will strictly adhere to them. I understand that my failure to do so may jeopardize my chances for a successful procedure.
- I have been given the opportunity to ask questions about the procedure, the risks, and the hazards involved.
- I understand that if I have any skin treatments, laser hair removal, plastic surgery, fillers 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 believe that I have sufficient information to give this informed consent.
CLIENT ACKNOWLEDGEMENT AND RESPONSIBILITY AGREEMENT
As a client, you have a responsibility to inform the technician (Leeann Royle) of all possible concerns. Please read the following and initial before each statement.
- I understand that I must inform my technician of all medications being taken by me, even though I have written it on the Medical History form. For example, pain control such as Aspirin may cause the blood to thin, and excessive bleeding may occur.
- I understand that it is my responsibility to advise the technician of ANY questions or concerns before they begin the procedure.
- I understand that the technician may not be from the local area and that it I would like to have any touch ups done by this technician, I will need to go where they are generally located.
- I am free from drug and alcohol use or any other substances.
- I am not pregnant.
** This is only for information purposes to inform the client so that any questions or concerns that may arise can be answered and discussed before a scheduled appointment**