Disclosure and Consent Form

Disclosure and Consent Form

Client Name: ______PLEASE INITIAL:

The nature and method of the proposed permanent makeup (cosmetic tattoo) procedure has been explainedto me by Heidi Jobeincluding the usual risks inherent in the procedure process, and the possibility ofcomplications during or following its performance. I understand there may be a certain amount ofdiscomfort associated with the procedure and that other adverse side effects may include minor andtemporary bruising, redness or other discoloration and swelling. Fading or loss of pigment mayoccur. Secondary infection in the area of the procedure may occur, however if properly cared for, is rare.

I have informed Heidi Jobe of any existing health problems.

I acknowledge that the procedure will result in a permanent change to my appearance and that norepresentations have been made to me as to the ability to later change or remove the results.

I understand that future laser treatments or other skin altering procedures, such as plastic surgery,implants and injections may alter and degrade my permanent makeup. I further understand that suchchanges are not the responsibility of Heidi Jobe.

I understand that permanent cosmetic makeup may cause MRI (Magnetic Resonance Imaging) artifacts and that there maybe a warming and/or tingling sensation in the permanent cosmetic procedural area during the MRI. It is understood that I should advise myphysician or x-ray technician that I do have permanent cosmetics (a tattoo) in the event a MRI of the head is prescribed.

It has been explained to me that immediately after the procedure(s) is completed, the color will appear darker than when the procedure heals. It has also been explained that within a short period of time, during the healing process, the color will lighten. I may lose up to 60% of color after the first treatment, which is normal. This is the reason for a touch-up.

I understand that I will be given the opportunity to look at the permanent makeup applied before my appointment is finished and make any adjustments at that time. I understand that once my appointment is completed, I should return for a follow up visit to complete the design. I further understand that no further treatment can be performed on the same area for 4 weeks from the original service. This allows the treated area to heal properly before any further procedures are done.

A touch-up will be required after your first visit. This allows your technician to put the finishing touches on your procedure; fill any place where you may have lost pigment; and fine-tune your result. Touch-ups completed within one year from date of service are $125. After one year touch-ups are $125 and up.

The fee for permanent makeup services has been explained to me and has been agreed upon. I understand the total fee for services rendered is due upon completion of the initial procedure(s) and that there will be separate fees for any future modification of the design.

Due to the fact that your approval is obtained prior to final selection of color to be implanted and design application(s) to be applied, I understand Heidi Jobeemploys a no-refund policy.

LIP COLOR ONLY: I understand that the lip procedure may cause a fever blister or cold sore to appear if I have this virus. I further understand that I must obtain a prescription for Valtrex and take the medication according to physicians directions (typically the day before, the day of, and the day after) your procedure. Failure to follow these instructions will most likely result in an outbreak and loss of lip color where the fever blister occurs.

I authorize Heidi Jobeto obtain pre-procedural and post-procedural photographs, and give her permission to use such photographs for publication and/or for teaching purposes, as she chooses.

______YES ______NO

I acknowledge the receipt of written instructions advising me of the proper care of my procedures and I recognize the absolute necessity for following these instructions.

I agree that liability is limited to the cost of theprocedure performed unless it is proven that Heidiwas negligent in the performance of herduties. In the event of disputes that cannot be amicably resolved, Heidi Jobeand client agree to binding arbitration to resolve disputes.

I have read and understand the contents of each paragraph above. I have received no unrealisticwarrantiesor guarantees with respect to the benefits to be realized from, or consequences of, the aforementionedprocedure(s). I acknowledge by signing this consent form, have been given the full opportunity to ask any and allquestions about permanent makeup procedure(s) and process(es) from Heidi Jobe.

Client:______Date:______

(First Visit Signature)

I personally reviewed the above information with my client, or the client’s representative.

______Date:______

Permanent Makeup Artist

(First Visit Signature)