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LIP BLUSHING CONSENT FORM
Identification Number (IC)
Consent & Release Agreement for Permanent Cosmetic
This form provides information to assist in making an informed decision of whether or not to undergo a permanent cosmetics application. If you have questions, please don‘t hesitate to ask. Although permanent cosmetic tattooing is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure. This is the process of depositing pigment into the top dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are strictly adhered to.
I am Aware & Agree To The Following
I am aware that it is not possible to predict how durable and intensive the lip colour will be and that durability and colour intensity depend on age, skin type, and environmental conditions of the treated person. I am aware that the treatment with the pigmenting needles can cause skin irritation and minor inflammation of the skin which usually disappears within 24-36 hours. If predisposed to cold sores, start taking medication immediately, as trauma to the lip can cause an outbreak and may affect pigment retention.
I have been informed that the pigments will appear darker within the first few days immediately following the procedure than the final result. It will be necessary to undergo a follow up treatment. I have been informed of the section of skin to be pigmented may be anesthetized/numbed with a surface anesthetic.
I have been informed that medicines affect different individuals in different ways. Just because side effects have occurred in some cases, it does not mean they will occur to me. Some common side effects anesthetics may include: Allergic reaction, light headedness, drowsiness/dizziness, vomiting, numbness of the tongue, unusually slow heartbeat.
I have received pre-and post-procedure instructions and I will receive an after-care kit and I agree to strictly adhere to such instructions. I understand my failure to do so may jeopardize my chances for a successful procedure. If I am on medication for depression or any other mood altering prescription, I will advise my technician
*I confirm that I have read and understood the above mentioned information. *I received a clear and understandable response to all of my questions. *The treatment procedure risks and post treatment care was explained to me in detail and I agree with it.
After Care for Lip Blush - Do not ...
Touch, bite or scratch your lips – touching or picking could cause irritation, infection & loss of pigment.
Exercise for at least 2-5 days after your treatment due to sweating. Gentle exercise is okay after the first few days.
Put lip liner, lipstick, lip gloss, cleansers, lotions etc. on or close to your lips for 1-2 weeks to avoid irritation & cross contamination.
Use saunas, steam rooms or swimming pools for 1 week due to sweating, risk of getting your lips wet & hygiene.
Have facials or other face beauty treatments done for 1 week to avoid irritation & cross contamination.
Use anti-aging creams, chemical peels, acids or retinols on or close to your lips ever!
After Care for Lip Blush - Do
Use a straw whist drinking and avoid salty or spicy food if your lips feel tender for the first few days.
Keep your lips as clean and dry, but moisturised, as you can for the first 5-10 days.
Use an icepack (wrapped in something clean) or take ibuprofen if your lips feel swollen and there is bruising present.
I hereby declare that I have been informed, in detail about the Lipblushin procedure which will be performed. I was informed that needles are used for the treatment to inject colour pigments into the lip membrane layer.
i hereby declare that i am not allergic to Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used.
I herby declare that i am not diabetic
i hereby declare that i am not on Accutane or prescription acne treatment
i hereby declare i am not prone to keloid scarring
I hereby declare i do not test positive for HIV or Hepatitus Virus
I hereby declare that i am not pregnant / breastfeeding
I hereby declare that i have had no Botox treatment for the past 28 days
i hereby declare that i have has no filler injections for the past 3 months
I hereby declare that i am not under treatment for Cancer / Radiation / Chemotheraphy
i hereby declare that i am aware there is NO GUARANTEE for the outcome of my procedure.
i hereby declare that i do NOT have any of the medical conditions that were mentioned in the above indemnity form.
I am aware that it is not possible to predict how durable and intensive the lip colour will be and that durability and colour intensity depend on age, skin type and environmental conditions of the treated person.
I am aware that the color retention / durability may varies on different lip type and may not absorb color well and may require more sessions to achieve the desired outcome.
I am aware that the treatment with the pigmenting needles can cause skin irritation and minor inflammation of the skin which usually disappears within 24-36 hours.
I hereby declare that I am under FULL UNDERSTANDING that the procedure is a Tattoo and a touch-up Session can only be done after 6 to 8 weeks but within 3 months .
IMPORTANT ( PLEASE ACKNOWLEDGE )
I acknowledge it is not reasonably possible for my technician to determine whether I might have an ALLERGIC reaction to the pigments, anesthetic or ointment used in this process. I agree to forego a patch test and accept the risk that such reaction is possible.
All touchup sessions must be completed 12 weeks from initial session. Failure to make this appointment will incur its corresponding fee or forfeited touchup session. Touch up can only be done after 6 to 8 weeks
i undertake not to make a claim against the therapist and The Lash Chapter and do hereby indemnify and hold the said business, it Owner and Employees harmless in respect of any claims of damage suffered by me in the consequences of undergoing the Lipblush procedure
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