Lip Color and Eyeliner Form

PERMANENT MAKEUP INFORMATION & CONSENT FORM

Please read all terms and condition before filling the form

I am over the age of 18, am not under the influence of drugs or alcohol and desire to receive the indicated permanent makeup procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.

Yes No

I hereby request and consent to the application of cosmetic tattooing and to have the following procedure(s) performed.

Upper Eyeliner Lower Eyeliner Full Lip Color

I understand that the process used in cosmetic tattooing is not a one-step process and may require multiple procedures to achieve the desired results. I realize that the healing process takes at least 4 weeks and that there will be at least 4 weeks between procedures, regardless of how many procedures are required to achieve the desired results

Yes No

I understand that each Kittaya Royal Brow Cosmetic Tattooing procedure does not include touch-up session which must be completed within 2-3 months of the initial procedure to qualify as a touch-up. Fees for touch-up sessions of procedures completed by Kittaya Royal Beauty are separate and not included in the original procedure price. Payment is rendered upon completion of the session. In the unlikely event of a dispute, I agree to arbitration and understand that there is a no- refund policy.

Yes No

I understand that this is a cosmetic tattoo and while, with time, pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, and use of chemicals such as Retin-A and Glycolic acids, they are permanent. Touch-up maintenance work will be expected in the future to keep it looking fresh.

Yes No

I acknowledge that no guarantees have been made to me concerning the results of this procedure and agree that the professional recommendation is a “natural look.”

Yes No

I understand that there are some known possible complications of permanent cosmetic procedures including redness, swelling, puffiness, corneal abrasions, dark patches, allergic reactions, tenderness, infection, or migration. In addition, I understand that there is a possibility of hyperpigmentation or scarring resulting from a procedure, especially in individuals prone to hyperpigmentation from a scar or other injury.

Yes No

If you are receiving a lip procedure and have a history of cold sores/fever blisters/herpes simplex, you will be required to contact your physician to obtain an anti-viral. You must strictly follow your physician’s instructions before contemplating any permanent cosmetic procedure around your lips. You will also need to start the anti-viral 3 days prior, the day of, and 3 days after your procedure, (a total of 1,000mg per day, minimum, for 7 days). This is very important to minimize your risk of cold sores. You also must stay out of the sun for at least 2 weeks. For the lips, you should refrain from the use of Aspirin containing medications, Ibuprofen, Coumadin and all blood thinning medications for 7 days before and 2 days after lip procedures. No medication should be discontinued without first consulting your physician.

Yes, I Understand

I understand that it is normal to lose approximately 1/3 of the color during the healing process. I realize that after the procedure the color will appear to be too dark and that in about 6 days the color will appear to change and that after about 10 days the color will appear in its final form and will appear softer since the color has moved from the dermal to the epidermal layers of the skin.

Yes No

I realize there will be a period of time when scabs may form and the skin may slough/flake off and that I am not to touch the areas during this time. Picking at, pulling or scratching off or otherwise removing sloughing skin may result in loss of color.

Yes No

I understand the nature of the procedure and possible complications or adverse effects that may occur as a result of applied pigments. Should any complications present themselves, I will contact Sisaket Body Rejuvenation immediately.

Yes No

I understand that in the event of an MRI or CAT scan I will need to inform my physician and/or technician that I have had permanent cosmetic procedures as a pulling, tingling, or burning sensation can occur during these tests. I also understand that having a permanent cosmetic procedure may restrict my ability to donate blood for one (1) year.

Yes No

I have received and acknowledged pre- and post procedure instructions and agree to strictly adhere to such instructions. I understand that achieving the results I desire will, in some measure, be determined by my compliance to post-procedure instructions.

Yes No

I accept responsibility for approving the color, shape, and position of the pigments that will be applied and will approve such applications before the procedure begins. I understand that actual color of the pigment may be modified slightly due to the tone and color of my skin and that because of the elasticity of the skin the shape may change slightly from that which I originally approved. I also understand that pigment unpredictably attaches to some areas of the skin more intensely than other areas and may appear darker or lighter than originally intended. However, I know that every effort will be made to make the final result flawless. I fully understand that this is a tattooing process and therefore is an art as well as a science.

Yes No

I understand that topical anesthetics will be used for my comfort and to enhance the permanent cosmetic procedure and experience. I realize that there are some people who are allergic to topical anesthetics and will make any such allergies or problems known prior to the procedures. I will inform Kittaya Royal Beauty of any condition which may make any of the procedures contraindicated including recent hepatitis or pregnancy, medications, health issues, or personal issues.

Yes No

I understand the taking of before and after photographs of procedures are required and that some photographs may be taken during the procedure. I also understand that exceptional photographs or results may be used in advertising or promotional materials and give permission for such usage. I also understand that any photographs will not be used for such purposes if I withhold permission.

Permission granted Permission withheld

I have been given an opportunity to ask questions about the procedures, equipment, past experiences, and/or the methods to be used as well as the risks and hazards involved and I believe that I have sufficient information to give this informed consent

Yes No

I have read (or have had read to me) and fully understand the contents of each item above as well as in the post- procedure care document. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s) I was of sound mind and capable of making independent decisions for myself and that no one has coerced me into making this decision.

Yes No