Informed Consent and Medical History

Color Me Beautifully Cosmetic Tattoo Informed Consent & Medical History Form

Client Name:______________________________

Date:_______________________________

Please circle all that apply:  I request permanent cosmetic makeup procedures:

Eyeliner        Lash Enhancement      Areola Tattoo      Eyebrow Powder Brow        Eyebrow Hair Strokes

Lightening/Lifting of Eyebrow Tattoo

Please read the following paragraphs and initial and date each to consent and agree:

*  I certify I am over the age of 18 and desire CarolAnne Velarde to perform the elective cosmetic pigmentation  procedure(s) understanding that  this procedure is for cosmetic purposes only and not for health reasons.  If any unforeseen conditions arise in the course of this procedure calling for her judgment for the procedures in addition to, or different from those now contemplated, I further request and authorize her to do whatever necessary in the circumstances.  I am aware that no guarantees have been made to me concerning the results of the permanent procedure(s)    Initial:    _______

* The nature and method of the proposed cosmetic tattoo procedure(s) has been explained to me by CarolAnne Velarde including the usual risks inherent in the procedure process, and the possibility of complications during and following the procedure(s).  I understand there may be a certain amount of discomfort or pain associated with the procedure(s) and that other adverse side effects may include minor and temporary bleeding, bruising, swelling, and/or redness or other discolorations.  Fading or loss of pigment may occur.  Unevenness in design may occur due to swelling. Secondary infection in the area of the procedure may occur, however, if all after care instructions (that are provided) are followed, is rare.  Initial:  ________

*   I have informed CarolAnne Velarde of any and all health problems   Initial:  ________

*   I acknowledge that complications including infection are always possible as a result of a cosmetic tattoo procedure(s), particularly in the event my post-procedural instructions are not followed.  Initial:  ________  

*   It has been explained to me that immediately after the procedure(s) is completed, the color will appear dark and the design will appear to be thicker. It has also been explained to me that within a short period of time (usually 5-7 days) during the healing process,  the color will lighten/soften and the design/procedure will heal thinner than it looked the day it was performed.   Initials:  ________

*   I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), or scarring is a possibility as a result of my body’s reaction to the skin being broken during the procedure.   I realize that my body is unique and that CarolAnne Velarde cannot predict how my body will react as a result of this procedure.   Initials:  ________

*   I am in agreement with and accept full responsibility for the decision of color, shape and position of the pigments that will be applied.  I understand the actual healed color of the pigment applied will be modified slightly due to my own unique skin undertones   Initials:  ________

*   I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin.   I realize that my body is unique and my practitioner, CarolAnne Velarde cannot predict how my skin may react as a result of the procedure.   I fully understand as with all such procedures that this is not a science but rather an art form and I acknowledge that NO guarantees have been made to me as to the result of this procedure. Some skin types will not accept or heal pigment in a consistent manner…your skin and how well you take care of your procedure (s) will determine your result.  I also realize that CarolAnne Velarde cannot predict how many visits it will take to complete my procedure.   Initial:    ________

*   I understand that future laser treatments may compromise the permanent makeup application.  I am also aware that other skin altering procedures, such as surgery, other cosmetic procedures including but not limited to: Gortex, Alloderm, Fat Transference, Dermagin, Silicone, Botox  or any other substance injected into or around the procedure area may compromise the existing procedure boundaries.  I further understand that such changes are NOT the responsibility of CarolAnne Velarde, and such changes in my appearance may NOT be correctable through further cosmetic tattoo procecures.  Initial:  _______

* I acknowledge that the procedure(s) will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.  Tattoo removal is a surgical procedure which may cause scarring and/or disfigurement.  Initials:  ___

*  I understand that tattoos may cause MRI (Magnetic Response Imaging) artifacts and that is a 1% to 2% chance of a reaction. Within that 1 to 2% for almost all there will be a warming and/or tingling sensation in the tattooed area from the MRI due to the iron oxide properties of some pigments.  It is understood that I should advise my physician that I do have permanent cosmetics (a tattoo) in the event an MRI procedure is prescribed Initial: ____

*   I understand that the permanent skin pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any product used.  I acknowledge that it is not reasonably possible to determine whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risks that such a reaction although rare, is possible. I have informed CarolAnne Velarde of any existing problems.  Initials: ________

*  At Color Me Beautifully, I, CarolAnne Velarde, do not have the medical expertise to administer and read a patch test, therefore, a patch test will not be administered.  If you believe you may have an allergic reaction it is advisable to see your physician for a patch test.  By initialing you agree to waive a patch test and release CarolAnne Velarde, technician, from liability if you develop an allergic reaction to the pigment. (Pigment contents are: iron oxide, lakes, alcohol, glycerin and sterile water) very similar to topical cosmetic makeup.   Initial:  __________

*   Tattoo inks, dyes and pigments have not been approved by the FDA and health consequences of using these products are not known. Section 119303 a (4) CA Safe Body Art Act.  No pigment is EVER reused.   Initial: ______

*   I have been informed that strict aftercare of my procedure is my responsibility.   I am aware that the results of my procedure may be compromised and even ruined by not adhering to all I have had explained to me, and agreed upon to perform, on the aftercare section of this contract.  Initial: _____

 For the purpose of documentation, and/or marketing, I consent to the taking of before and after photographs/videos of my procedure(s) which become the sole property of Color Me Beautifully and my technician CarolAnne Velarde to own/use as she chooses.      Initial:  ___________

*  The fee for my cosmetic tattoo procedure(s) have been explained to me, including the initial procedure fee, touch-up fees and maintenance fees. These fees are understood and agreed upon.  I understand the total fee for services rendered is due upon completion of the initial procedure and that there WILL BE separate fees for any touch-up/follow-up work.    Initial:  ___________

*  I understand that CarolAnne Velarde  DOES NOT  include a free touch-up appointment(s) in her initial procedure price.  All touch-up/follow-up appointments  ARE a separate fee.  A “follow-up/ top off” appointment is often needed to complete, adjust, or fine tune the first initial procedure between 6-8 weeks of initial procedure.  This “follow-up/top off” appointment will be charged a $75 set up fee and this fee will be guaranteed for 5 months only following your initial procedure date.  This 5 months time frame allows for 2 “follow up/top off” color boosters IF NEEDED.  Any and all other appointments after 5 months of original procedure date are referred to as color refreshers and the current fees, at such date of procedure, will apply.    Initial:  ___________

*   I understand and agree to accept that CarolAnne Velarde may at any time and for any reason refuse to perform services on me.   Initial:  ________

*   Due to the fact that your approval is obtained prior to final selection of color to be implanted and design application(s), that all the facts about cosmetic tattooing have either been disclosed or discussed with you, and that you have been given full opportunity to have any and all questions answered, CarolAnne Velarde employs a NO REFUND policy.    Initial:  __________

*  This contract is to remain in effect for as long as I remain a client of CarolAnne Velarde and all its contents apply whenever work is being performed on me by CarolAnne Velarde.  It is my responsibility to inform CarolAnne Velarde if any changes have occurred in my medical history.  Initial:  _____

*   I have read and understand the contents of each paragraph above.  I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of the aforementioned procedure(s).   Initial:  __________

 

I (print name)______________________________, acknowledge by signing this consent form, have been given the full opportunity to ask any and all questions about cosmetic tattooing procedure(s), it’s process, and the risks involved from CarolAnne Velarde.  The decision to have cosmetic tattooing procedure(s) performed is my own and I understand and accept all risks involved, therefore releasing CarolAnne Velarde of any and all legal liability.  CarolAnne Velarde is an artist, a highly trained, experienced and skilled artist and makes no claims to be anything more.  Permanent makeup/cosmetic tattooing is not a medical procedure but an art form, the art of tattooing.  NO REFUNDS….NO EXCEPTIONS.

* I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement:

Client Signature: _____________________________________ Date: _____________________________________

I have personally reviewed the above information with my client or the client’s representative    ________________________________

 

Name Date Gender

Female    /    Male

Age
Address City State Zip
Employer / Occupation Home Phone Cell Phone
How did you select me for your procedure services? E-Mail
PLEASE READ CAREFULLY AND ANSWER ALL QUESTIONS….DO NOT LEAVE ANY UNANSWERED AND PROVIDE ADDITIONAL INFORMATION BELOW
1 YES NO Are you pregnant or nursing? 27 YES NO Do you have prosthetic implants?
2 YES NO Have you had any alcohol in the last 24 hours? 28 YES NO Do you consume aspirin daily?
3 YES NO Have you ever had cold sores or fever blisters? 29 YES NO Are you under treatment for depression?
4 YES NO Do you have any allergies to latex? 30 YES NO Do you have any type of herpes? Ever had a herpetic outbreak in your eyes?
5 YES NO Have you had a laser or chemical peel within 6 months? 31 YES NO Are you sensitive to petroleum based products?
6 YES NO Have you ever had any permanent cosmetics or tattoos applied? 32 YES NO If you have permanent cosmetics or tattoos, did you have any problems with healing after they were applied?
7 YES NO Do you bruise easily for no obvious reason? 33 YES NO Are you undergoing radiation or chemo-therapy treatment?
8 YES NO Do you routinely use Retin-A, glycolic, or other exfoliating products? 34 YES NO Are you now, or have you ever been on the acne treatment Accutane?
9 YES NO Do you wear contact lenses? 35 YES NO Are you wearing a pacemaker?
10 YES NO Are you allergic or sensitive to any metals, for instance metals used for jewelry? 36 YES NO Do you take prescription drugs?
11 YES NO Do you have any problems healing? 37 YES NO Are you anemic?
12 YES NO Is your skin oily? 38 YES NO Do you have a history of skin sensitivities?
13 YES NO Do you use tobacco? If you use tobacco you may heal slower and this affects the timing on scheduling a touchup appointment, if applicable. 39 YES NO Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedures?
14 YES NO Do you have any heart conditions? 40 YES NO Do you have allergies to makeup?
15 YES NO Are you diabetic? If so, Type 1 or Type 2? 41 YES NO Do you have dry eyes?
16 YES NO Do you have any autoimmune disorders? 42 YES NO Do you intentionally tan – Direct sun or tanning bed?
17 YES NO Are you sensitive or allergic to hand creams or body lotions? 43 YES NO Do you personally have any history of cancer?
18 YES NO Are you allergic to Lidocaine or Epinephrine? 44 YES NO Do you have a history of stroke or heart attack?
19 YES NO Do you have botox injections? 45 YES NO To your knowledge are you allergic or resistant to over the counter level numbing products such as ELA-Max?
20 YES NO Do you menstruate?  If yes:

Next cycle date_________________

46 YES NO Do you hypo-pigment? (Lack of pigment on the skin)?
21 YES NO Do you hyper-pigment? (Tendency to develop dark spots on the skin from wounds or sun)? 47 YES NO Are you allergic to hair dyes? ANY ALLERGIES?
22 YES NO Do you tend to develop keloid or hypertrophy scars? 48 YES NO Do you have glaucoma or any other eye disease?
23 YES NO Do you scar easily from minor skin injuries? 49 YES NO Do you have arthritis?
24 YES NO Do you have any seizure related conditions? 50 YES NO Do you have high or low blood pressure?
25 YES NO Do you have a tendency to faint or become dizzy? 51 YES NO Do you have sinus problems?
26 YES NO Do you bleed excessively from minor cuts? 52 YES NO Do you have any type of hepatitis?

If you answered “Yes” to any questions above, use the space below and the reverse side of this form to provide an explanation.  Correlate your explanations to a specific question number.  A “yes” answer does not indicate you are not an acceptable candidate for permanent cosmetics.  It may simply be information that is valuable to me as your technician as each person’s body is unique, or it may indicate that based on any health conditions that affect healing, it would be advisable or required for you to consult with your physician before proceeding.  If this form has not addressed a medical condition you have, please list it below.

PLEASE ALSO LIST ANY AND ALL MEDS YOU ARE CURRENTLY TAKING.

 

Client Signature__________________________

Date________________________________