MICROPIGMENTATION CONSENT AGREEMENT

This form is designed to give information regarding semi-permanent eyebrow, lips and eyeliner micropigmentation application. If you have questions, please don't hesitate to ask. Micropigmentation is the process of depositing pigment into the epidermal layer of the skin and is a form of cosmetic pigmentation. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are stickily adhered to. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.

POSSIBLE RISKS AND COMPLICATIONS

• Pain: To minimize discomfort, we will apply topical anesthetic on the working area.
• Uneven Pigmentation: This can result from poor healing. Your follow up appointment will likely correct any uneven appearance.
• Anesthesia: Topical anesthetics are used to numb the area to be pigmented. Lidocaine, Prilocaine, Benzocaine, Tetra Caine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these, please inform us now.
• Allergie Reaction: We use organic pigments for all our pigmentation procedures. This helps minimize possibility of allergic reaction.

Consent and release for procedures performed:

STATEMENT OF CONSENT AND RECITALS:

(PLEASE READ AND INITIAL ALL LINES)

Human Error Acknowledgment:

I understand that aesthetic treatments are performed by qualified clinicians using professional equipment and established protocols. However, I acknowledge that, as with any procedure involving human involvement, there is a possibility of unintended outcomes due to human or technical error. By signing this consent, I accept this inherent possibility and agree that The Abram and its staff shall not be held liable for minor or unintentional errors occurring during the course of treatment, provided that reasonable care and professional standards are followed.

Pictures and Videos:

I understand that videos and photos will be taken for medical documentation purposes and will be used only for treatment comparisons and tracking progress milestones.

Initial:

I certify that I have read the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered.

CLIENT MEDICAL HISTORY FORM

Do you presently have or previously had any of the following: (check yes or no)

I agree that all the above information is true and accurate to the best of my knowledge.