I, ____________________________________________, as a client have requested that you describe the procedure to the utilized so that I may make an informed decision whether or not to undergo the procedure.
You have described the recommended procedure to be used as Micro Pigmentation Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin. Micro pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.
I voluntarily request as my intradermal cosmetic technician, CFYB and such association and technical assistance as she may deem necessary to perform on my body the following procedure (circle one):
EYEBROWS EYELINER LIPLINER FULL LIP COLOR
AREOLAS SCAR CAMOUFLAGE STRETCH MARKS OTHER:_______________________
I agree to (circle one):
RECEIVE WAVE a patch test prior to application and I agree to release CFYB, and pigment manufacture(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. A patch test is the process of applying pigment to the skin in the hairline to test for an abnormal reaction. If a patch test is requested, you will be charged an additional fee of $35.
_____ I hereby authorize CFYB to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.
_____ I hereby authorize CFYB to take photographs of the work performed both before and after treatment to be maintained only in file.
_____ I have informed CFYB that I am in good health and not under the care of any physician.
____ I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure.
____ I understand that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results.
____ I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment;
______ I am aware that allergic reactions to pigment are very rare, however they can and do occur and when they occur they can be serious and especially difficult and very troublesome to treat.
____ I understand that this procedure may involve pain and discomfort (CFYB uses a topical numbing to aid in any discomfort).
____ I understand the markings are permanent and that there is a possibility of hyper pigmentation resulting from procedure, especially in individuals prone to hyper pigmentation from a scar or other injury.
____ I understand that a follow up procedure may be required. Follow up procedures are to be used within 8 weeks of initial appointment. Cancellation of follow up’s must be done within 48 hours of procedure in order to not incur fees. If follow appointment is either cancelled, I become a no show, or I take my appointment after 8 weeks of initial procedure, I acknowledge that the follow up appointment is no longer considered “included in initial fee,” but is now a fee of $95 paid at the time of procedure.
____ I understand that there is a chance that I may experience a corneal abrasion (only applies to eyeliner procedures).
____ Other risks involved with the procedure may include, but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction (s) to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.
____ I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with procedure planned for me.
____ I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.
____I understand that this is a cosmetic tattoo and with time pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, and use of chemicals such as Retin-A and Glycolic acids.
____ I understand that there is No Refund policy on permanent makeup. For some reason if my pigment does not stay or needs more touchups I agree to contact CFYB for further discussions on additional applications. However, I am fully aware that Refunds will not be received.
____Payment is rendered upon completion of the session. In the unlikely event of a dispute, I agree to arbitration.
____ I understand that if I have an infection, adverse reaction or allergic reaction the procedure I must notify CFYB, a health care practitioner, IL Department of Health,
____ I certify this form has been fully explained to me and I have read it or it has been read to me. I understand its contents.
____ I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its contents.
____ I understand that Touch-up maintenance work will be expected in the future to keep my procedure looking fresh. I further understand that regular touchups are recommended every 18 -36 months at a discounted cost. However, if I wait after the recommended 36 month window I may be required to pay full price for my touchup procedure.
____I have read and understand the contents of each item above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s). I was of sound mind and capable of making independent decisions for myself and that no one has coerced me into making this decision. I also agree not to hold neither CFYB, Agata Kubiak or Bernadreta Wilczynska and or anyone who may be assisting her liable for any reactions, outcomes, or occurrences that may or may not result from having this procedure(s).
Signature _______________________________________ Date_______________