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Design Artist/Technician Kristi Miller 715-520-3147 CONSULTATION CONSENT
Print Name:___________________________________________Date:___________________________



1. The procedure that I am about to have has been explained to me by Kristi Miller, (Technician). I have been informed of the risks and complications that can possibly take place during and after the procedure. 2. I understand that there may be some pain involved, though numbing creams, such as Lidocaine, are used during the procedure. Each person has a different tolerance level and pain will be according to each individual’s pain threshold. 3. I have been informed that other adverse side effects, although rare, can include, swelling, temporary minor bleeding, redness and pinkness, soreness and bruising, (extremely rare). 4. I understand that there will be some fading of color. The oilier the skin, the more fading can occur. The above practitioner has not guaranteed me as to how much color will stay. 5. Permanent makeup is a process. It often requires touch-up applications. It is recommended that a follow-up, touch- up be done after 3 weeks of healing. Each touch-up is $100. Maintenance of permanent makeup can be done quarterly or less often. As long as you do not exceed one year between appointments, it will be a fee of $100. If you exceed one year, it is $250, as the original application. 6. I accept full responsibility for the shape of each and every procedure that I will be having done. For example, I take responsibility for my eyeliner whether it is of thick, thin or medium thickness. I take full responsibility for my eyebrows as to the shape, color and placement of them. I take full responsibility for my lips, the color and shape. (Technician and I agree on procedures being done, prior to and during the procedure.) 7. I have been advised not to take aspirin or consume a lot of caffeine for 24 hours prior to the procedure because it can thin the blood and may cause my color to bleed out during the procedure. I may take Tylenol or Ibuprofen. 8. I have been given home care instructions on how to care for my procedure after it has been completed I have read it thoroughly and understand it and agree to adhere to it. 9. I understand that secondary infection can occur although it is rare. I agree to follow all home care instructions in order to prevent this. 10. I understand that if I ever had a cold sore or fever blisters on my lips then I may break out with fever blisters on the lips following a lip procedure. If I am prone to cold sores I may desire to obtain a prescription for something such as Zovirax and take as prescribed by my doctor. 11. If I am to have eyeliner done, I should not wear any contact lenses during the procedure and up to 72 hours after the procedure. I have also been told that previous patients have found relief from

excessively watery eyes by taking an antihistamine, such as Benadryl or Claritin one hour before the procedure. This is not being prescribed to me. It is optional if I choose to do so. Please check yes or no as to whether or not you currently have or have ever been diagnosed with the following or are taking any of the following medications: 1. Keloid Formation: ____Yes ____No (If client has concerns about possible Keloids, a patch test behind the ear must be performed three months prior to procedure to see if any Keloid has formed. If as this time, no Keloid has occurred, client may make the decision to get a procedure done. However, the procedure will be performed only using the manual technique since the manual technique only deposits pigment .5mm or less below the surface of the skin. (Keloids are known to form secondary to deep incisions.) 2. Use of Acutane/Retin A: _____Yes_____No These drugs have been known to produce pigmentary changes, (Color migration too). Drugs must be discontinued in order for procedure to be performed. The same holds true for any other drugs for which side effects may be pigmentary changes. If you are currently taking drugs, please contact your physician in order to determine the likelihood of pigmentary changes. 3. Active Dermatological Disorder: _____Yes_____No These may include skin disorders such as Psoriasis, Warts, Active Herpes Simplex, etc. 4. Currently Pregnant: _____Yes_____No Because of hormonal changes during pregnancy, pigmentary changes can take place Therefore it is advised to wait until three months post pregnancy before having any procedures. 5. Over-use of Alcohol/Drugs: _____Yes_____No I have been advised that alcoholism or drug use can cause the skin to take on pigmentary changes and the procedure can be more painful. Therefore it is advised to discontinue use for thirty days prior to procedure. 6. Diabetes: _____Yes_____No Healing is sometimes slower for Diabetics. Therefore your physician should be consulted prior to the procedure. A patch test can be performed upon request in order to watch the healing process before the entire procedure is done. 7. Epilepsy: _____Yes_____No Please advise practitioner what to do in the event that a seizure would occur during a procedure. 8. Hemophilia: _____Yes_____No This client should not have any micro pigmentation procedure.

Signature: ______________________________________________Date:___________________________

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