SMP Client Consent Form

CONSENT TO APPLICATION OF SCALP MICROPIGMENTATION PROCEDURE

This form is required to be completed BEFORE any service. Please read, initial, sign, and submit this form PRIOR to your appointment. All fields with an asterisk (*) are required.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home/Cell Phone

(###)

###

####

Work Phone

(###)

###

####

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

PROCEDURE(s): SCALP MICROPIGMENTATION

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s).

There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. Please check below to inform me if you consent or waive the patch test. If waived, I release the technician from liability if I develop an allergic reaction to the pigment.

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.

I have received pre- and post-procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician.

I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s). I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.