LIP BLUSHING CONSENT FORM

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Identification Number (IC)

I am Aware & Agree To The Following

WHO IS A GOOD CANDIDATE FOR LIP BLUSH TATTOO? You're a healthy person, over 18, not pregnant or nursing, and don't have the following health condition.
WHO IS NOT A CANDIDATE FOR LIP BLUSH TATTOO? Under Age 18 Pregnant or Nursing History of Keloid Scars Iron Deficiency Anemia Hemophilia Epilepsy AIDS (HIV) Hepatitis/Jaundice
WHO IS NOT A CANDIDATE FOR LIP BLUSH TATTOO? Accutane in the past year (you must be off of Accutane for one year) Diabetic (please consult with your doctor)
Have glaucoma Taking blood thinning medications Skin cancer or any kind of skin disorders near the treatment area (i.e. shingles, psoriasis, rashes, eczema or anything else near lips) Bleeding disorder Problems with Healing Have allergies to alcohol, numbing agents, or makeup colours
Have heart problems, healing disorders, uncontrolled high blood pressure You develop infections easily Core Sores outbreak on the day of the appointment, your procedure cannot be performed (If you have a history of cold sore, it is recommended to go to your family doctor and get Valtex orZovirax or another antiviral medication prescribed to take 5 days prior procedure, the day of, and 5 days after) Have previous tattooed lips that is too dark or large.
I am aware of the above conditions and will proceed with the session

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