Sample Informed Consent Form For Microbladers and PMU Artists

YOUR COMPANY NAME HERE                            LOGO

YOUR PHONE / ADDRESS

INFORMED CONSENT FORM 

FULL NAME : …………………………...............................................……………. DOB : …………………….....................…………

Address : …………………………………………………………………………………………..............................................................................................

Cell : ……………………………………..................................................................

Pigment Selected/Procedure:

Date:

Touch Up Pigment/Date::

The nature and method of the proposed permanent makeup procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bruising, redness or other discoloration and/or swelling. Fading or loss of pigment may occur. Infection in the area is very rare if properly cared for, but may occasionally occur.

By signing below, I specifically acknowledge that I am over 18 years and I have been advised of the facts and matters set below, and I agree as follows: Please initial;

_____ I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance 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 risk that such reaction is possible.

_____I acknowledge that complications as a result of permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.

_____I realize that my skin is unique and neither our salon, nor its employees can predict how my skin may react as a result of the procedure.

YES / NO I have previously had micropigmentation performed before on the same area that I am asking ----------------------- to work on today.

If YES, I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which our salon has no control. I understand that additional appointments after the initial and follow up appointments may be required.

_____I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representation have been made to me as to the ability to later change the results.