CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETICS
This document provides the necessary information to help you make an informed decision about undergoing a permanent cosmetics procedure. Please read it carefully and ask any questions before proceeding.
The permanent cosmetics procedure involves implanting pigment into the dermal layer of the skin. While the procedure is effective for most clients, results cannot be guaranteed. Instruments that penetrate the skin or come into contact with bodily fluids are sterilized and properly disposed of after use, following strict sanitary standards.
Immediately after the procedure, the color will appear darker and more vibrant than the final result. Within 5-7 days, the pigment will lighten by 50-70%, soften, and achieve a more natural appearance. Over time, the pigment may lighten by 30-70%, depending on skin type, metabolism, and lifestyle. As the pigment gradually fades, touch-ups will be required to maintain the desired result.
1.FDA DISCLAIMER
2.PHOTOGRAPHY AND VIDEOGRAPHY RELEASE CONSENT
3.Special requests, concerns, or remarks for the technician:
4.STATEMENT OF CONSENT AND ACKNOWLEDGMENTS
5.TOUCH-UP POLICY
6.GENERAL AFTERCARE TIPS FOR ALL AREAS
The pigments used in permanent cosmetic procedures are not FDA-approved for injection into the skin. While pigments are widely used in the industry and considered safe by professionals, the FDA does not regulate or approve pigments specifically for permanent cosmetic tattooing.
By proceeding with this procedure, you acknowledge that you have been informed of this disclaimer and accept the associated risks.
Signature: ____________________________
Date: ____________________________
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For documentation and insurance purposes, “Before” and “After” photos/videos will be taken and kept on file. With your permission, these materials may also be used for advertising purposes, including portfolios, websites, and printed materials.
Please indicate your preference:
YES, feel free to use them
NO, please do not use them
Signature: ____________________________
Date: ____________________________
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POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS
Pain: Some discomfort may persist despite the use of topical anesthetics.
Infection: Rare but possible. Keep the area clean and avoid touching it with unwashed hands.
Uneven Pigmentation: Uneven pigment distribution may result from poor healing, infection, or other factors. A follow-up appointment will address these concerns.
Asymmetry: Natural facial asymmetry may require minor adjustments during the follow-up session.
Swelling or Bruising: Typically resolves within 1-5 days.
Eye Exposure: For eyeliner procedures, protective eye drops are used to minimize risk.
Anesthesia Risks: Allergies to anesthetics (Lidocaine, Prilocaine, Benzocaine, Tetracaine, Epinephrine) must be disclosed.
MRI Effects: Inform healthcare providers about your permanent cosmetics before undergoing an MRI.
Fever Blisters: If prone to cold sores, consult your doctor for antiviral medication before the procedure.
Allergic Reactions: Rare but possible.
Alternative Option: You may choose to continue using traditional makeup instead of undergoing this procedure.
Signature: ____________________________
Date: ____________________________
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Please read and initial each statement:
_____ I have been given and understand the aftercare instructions and will follow them carefully.
_____ I understand that swelling, redness, and bruising are normal side effects.
_____ I acknowledge that sun exposure, tanning beds, and certain skincare products may affect results.
_____ I will inform medical professionals about my permanent cosmetics before undergoing MRI or medical procedures.
_____ I take full responsibility for communicating my desired shape, color, and placement to the technician.
_____ I understand that pigment color may fade or change over time, requiring future touch-ups.
_____ I understand the risks involved, including infection, uneven pigment, and poor color retention.
_____ I have been informed of the procedure costs, including fees for follow-up appointments.
_____ I understand that funds for elective procedures are non-refundable.
_____ I take full responsibility for my decision to undergo this procedure.
I certify that I have read and understood this document. I have had the opportunity to ask questions, and all my concerns have been addressed. I authorize Elena Saenko, PMU Technician, to perform the following procedure(s):
Printed Name: ____________________________
Signature: ____________________________
Date: ____________________________
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Touch-Ups Within 4-8 Weeks: Touch-ups are not included in the initial procedure cost and will be charged 50% of the initial procedure fee.
Touch-Ups Within 6-18 Months: Touch-ups performed within 6-18 months after the initial procedure, or after a short-term touch-up, will be charged 80% of the initial procedure fee.
Touch-Ups After 18 Months: Touch-ups performed after 18 months will be charged at full price as a new procedure.
Note: Funds for elective procedures are non-refundable.
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1.Use Recommended Products: Use the saline solution and Vaseline with Vitamin A&D as instructed by your technician.
2.Do Not Pick or Scratch: Avoid picking, scratching, or peeling scabs to prevent pigment loss or scarring.
3.Avoid Makeup: Refrain from applying makeup to the treated area until it is fully healed.
4.Limit Water Exposure: Avoid heavy sweating, swimming, saunas, or prolonged water exposure on the treated area.
5.Follow Instructions: Adhere to all specific aftercare instructions provided by your technician.
6.Schedule Touch-Up: Plan a follow-up appointment within 4–6 weeks to ensure optimal results.
7.Monitor for Infection: If you notice increased redness, swelling, warmth, or unusual discharge, contact your healthcare provider immediately.
8.Take Responsibility: Failure to follow aftercare instructions will result in the client assuming full responsibility for the final outcome of the procedure.
By adhering to these aftercare instructions and using the recommended products in your aftercare kit, you will ensure proper healing, vibrant color retention, and long-lasting results.
Studio PMU Elena Saenko LLC
If you have any questions or require further assistance, please contact us promptly.
Thank you for choosing Studio PMU Elena Saenko LLC!
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