Smoky Eyeliner Informed Consent


INFORMED CONSENT

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE THAT YOU UNDERSTAND AND ARE IN AGREEMENT WITH EACH STATEMENT BY PLACING YOUR INITIALS BESIDE EACH ONE.

 

1. I understand and accept that such a procedure is a process, often requiring multiple applications of color to achieve desirable results and 100% success cannot be guaranteed.
I accept 

 

2. I have received, reviewed and understand the written and verbal post-procedural instructions as given to me and agree to follow them.

I accept 

 

3. I understand before and after photographs of procedures may be taken and the rights to all photographs taken belong to Beauty By Katelyn Mccloy and therefore may be used in any way Beauty By Katelyn Mccloy so chooses.

I accept 

 

4. I understand that any hair removal, such as tweezing, waxing or electrolysis, must be done no sooner than 1 week prior to the procedure and at least 2 weeks after the procedure.

I accept 

 

5. I am aware that if I am to have an MRI anytime after the procedure, I must advise the radiologist that I have permanent makeup.

I accept 

 

6. If I wear contact lenses, I understand that I must remove them prior to an eyeliner procedure.

I accept 

 

7. If I wear false eyelashes, I understand that I must remove them prior to an eyeliner procedure.

I accept 

 

8. I understand that the procedure(s) will fade, and this fading can alter the original pigment color. Fading can be remedied with a touch-up visit.

I accept 

 

9. I understand this is an elective, cosmetic procedure that is not an exact science and is not medically necessary.

I accept 

 

10. I understand the following may occur: minor and temporary bleeding, bruising, redness or other discoloration, swelling, fading or loss of pigment, and cold sores (on lips, for individuals who are prone to them).

I accept 

 

11. I understand that laser hair removal procedures may turn lip pigment dark or even black.

I accept 

 

12. I give full consent to Beauty By Katelyn Mccloy to confer with my physicians or medical practitioners for medical information required for the safety of my procedure(s).

I accept 

 

13. I agree to accompany my permanent cosmetic practitioner to the emergency room in the event they were to be accidentally stuck with my needle and agree to take a blood test for their safety, as well as disclose all test results to my practitioner.

I accept 

 

14. I have disclosed all pertinent medical history and allergies to Beauty By Katelyn Mccloy to ensure the safety of my procedure(s).

I accept 

 

ACCEPTANCE:

I have thoroughly read and understood this document. The risks involved with my procedure(s) have also been verbally explained to me. I fully understand the written and verbal post care instructions. I certify that all of my questions have been answered and I accept full responsibility for any complications that may arise during or following the procedure(s) to be performed at my request.

My procedure(s) today is(are): (Check All That Apply)

Name:  

Age:  

Date of Birth:   

 

Leave this empty:

Signed by Katelyn McCloy
Signed On: October 1, 2018

Beauty By Katelyn McCloy https://beautybykatelynmccloy.com
Signature Certificate
Document name: Smoky Eyeliner Informed Consent
Unique Document ID: 9475f2ff382e1b884e2a7fe48e6d398f23ac638c
Timestamp Audit
July 10, 2018 4:26 pm EDTSmoky Eyeliner Informed Consent Uploaded by Katelyn McCloy - katelynmccloy@yahoo.com IP 69.180.24.219, 127.0.0.1