Disclosure and Release Form
for Implantation of Pigment
Eyeliner. Eyebrows. Lips. Beauty Mark. Hair Simulation. Camouflage.
CosmeticTransformations.biz appreciates your patronage and interest in permanent makeup enhancements. Please read and fill out this form completely.
I HAVE COMPLETELY READ, UNDERSTAND AND AGREE WITH THE FOLLOWING:
_____ That no warranty or guarantee has been made to me as a result of this micropigmentation procedure and the result cannot be guaranteed.
_____ That there may be risks and hazards related to the performance of this procedure.
_____ That there is potential for discomfort during the procedure and the healing process.
_____ That although tattooing is considered permanent, it may fade with time.
_____ That a tattoo can only be removed with a surgical procedure, and that removal may leave permanent scarring or disfigurement.
_____ That misplacement of the dye can occur under rare circumstances, requiring excision of the misplaced dye.
_____ That I have been given the opportunity to ask questions about the procedure, the risks and the hazards involved.
_____ That I believe I have sufficient information to give this informed consent.
_____ That CosmeticTransformations.biz will not, under any circumstance, perform any permanent makeup procedures on me if I am known to have any allergies.
_____ That I have not taken any blood thinning medication or consumed alcohol within the last 24 hours.
_____ That it is my responsibility to express any concerns I may have during consultation, before, not during the procedure.
_____ That I understand this procedure is a process, and subsequent visits might be necessary to achieve desired results. The cost of subsequent visits is $180 per session within 6 months. Satisfaction could take multiple sessions.
_____ I hereby release CosmeticTransformations.biz and Jennifer Lallave of all claims for injury, seen or unseen that may occur as a result of this procedure.
_____ I fully understand the questions, terms and conditions of this disclosure and release agreement, and all have been explained to me.
_____ I certify that this disclosure and release agreement was completed by me and that all entries in it and information are true and complete to the best of my knowledge.
_____ I have read and understand the attached after care treatment instructions and recommendations. I understand my responsibility to follow them to ensure proper healing of the treated area.
_____I understand pictures and videos will be taken for documentation purposes and will be kept in my personal file.
_____ I authorize CosmeticTransformations.biz to use before and after pictures
and/or videos of me, for promotional purposes.