PMU CLIENT FORM

CONSENT TO PERMANENT MAKE-UP APPLICATION, RELEASE AND WAIVER OF ALL CLAIMS.

Lip Blush, Microblading, Eyebrows, Eyeliner, Freckles, Beautymark

I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent make-up from THIRDEYE STUDIO (hereafter called “Technician”). I acknowledge that obtaining permanent make-up is my choice alone. The application of permanent make-up will result in a permanent change to my appearance, and that needles and inks will go into my skin.

No representations have been made to me as to the ability to later restore the skin involved in permanent make-up to the original condition.

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my blood. If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications necessary to promote the healing.

I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the permanent make-up, or any open wounds or lesions at the site of the tattoo. I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.

I have advised the Technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reaction to the permanent make-up process.

I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo at this time.

I acknowledge infection is always possible as a result of permanent make-up application, and I agree to follow all suggested instructions concerning the care of the permanent make-up site while it is healing.

I acknowledge and give consent to this permanent make-up studio to use images of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed, and or television etc. Please add yes or no.

I accept the responsibility to explain to my technician any desires for specific color, shape, and/or position for any procedure done today. I understand that implanted pigment color may slightly change or fade over time due to circumstances beyond control and that I will need to maintain the color with future applications and a touch up session within 60 days. I understand I will have permanent make-up applied using appropriate instruments and sterilization techniques. I understand that the permanent make-up site usually takes 2 weeks or longer to heal.

LIP CLIENTS: Herpes Simplex Virus If you have an outbreak, you must reschedule your appointment and wait until it has healed at least 6 weeks. If you have a history of cold sores, please ask your doctor for an antiviral medication and take 5 days pre and post. You must wait 4 weeks post lip filler for lip blush.

I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors, and the management of the permanent make-up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure. I am aware that permanent cosmetic inks, dyes, and pigments have not been approved by the federal Food and Drug Administration.