COLOUR COSMTETICSTUDIO, inc.
COLOUR COSMTETICSTUDIO, inc.
  • INFORMED CONSENT TO PROCEDURE    
  • Client name__________________________
  • Please print out , fill out and bring with you.  (please initial each line)
  • I realize this is an elective cosmetic procedure and is not medically necessary and that                 100% perfect symmetry or perfect expected results are not achievable with tattoo as most faces and skin are normally asymmetrical and that many factors effect the final outcome x________
  • I understand that this procedure will fade over time and  this fading can alter the original pigment color and that this fading determines that it is a time for a touch-up  visit  x______
  • I absolutely understand and accept that a tattoo procedure is a process, often requiring multiple applications of color to achieve desirable results and that 100% success/color retention cannot be guaranteed. I  further understand that the color selection and color results in all procedures are not an exact science and may not heal exactly as expected based on patch test. Depending on the procedure(s), which I select,  I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lip liner and/or full lip, SMP or Para-medical procedure as determined by my artist and myself.  x________
  • I understand and agree that NO refunds will be issued for:  appoinments not kept, less than desired or expected results and that NO guarantees of a perfect outcome can be made  as my skin is a living organ and it is impossible to guarantee the outcome,  color, retention, fading or otherwise unsatisfactory results and that this is not the fault of the trained tattoo artist :  _____________________________or the company of Colour Cosmetic Studio, inc. x________
  • It has been explained to me that the following possibilities may occur:  Minor and temporary bleeding, bruising, redness or other temporary discoloration, swelling, fading or loss of  pigment; fever blisters on the lip area following lip procedures.
  •  I am aware that if an infection occurs after my procedure,  I will seek appropriate medical care immediately.   x______   
  •  I understand that only sterile single use needles are used  and opened before me, but this is not considered a sterile procedure.  Colour Cosmetic Studio, inc. is in full compliance with              Article 4-A Regulation of Body Piercing and Tattooing.  x_______                                                                    The link can be found @ https://www.health.ny.gov/community/body_art/article_4a.htm 
  • I have been given verbal and written aftercare instructions and agree to follow them exactly as explained & written. x_________
  • I have read the pre & post care procedure forms that were emailed to me from the company email with a web link provided and understand what is required of me before and after my procedure x_______
  • If I had permanent cosmetics performed previously by another practitioner,  I do not hold  Colour Cosmetic Studio, inc. responsible  for any  future allergic reactions, complications,  color changing   or fading or any adverse reactions after my procedure.  x_______
  • I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery,  skin care treatments, exfoliations,  Botox (or similar product), facial injected fillers  before or after my procedure and  I assume this responsibility.  x________
  • I give my consent to Colour Cosmetic Studio, inc. to confer with my physicians for medical information required  for the safety  of my procedures. I agree to accompany my practitioner to the emergency room  in the event they were to be accidentally stuck with my needles and take a blood test for their safety & disclose all test results to my practitioner x_______. 
  • I am aware if I am to receive an MRI after the procedure,I must tell the Radiologist that I have       iron oxide pigments x_________
  • I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging,  photo facials, removal of lines could / will turn permanent make up dark or even black.   I agree to inform my technician that I have a Cosmetic tattoo(s).   x_________
  • If I am a contact lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.  x__________
  • I give  Colour Cosmetic Studio, inc. permission to post photos of my procedures to the websites used for marketing & instruction purposes. Said photos are only of the body part that was tattooed.  Full face are not posted without permission from client  except in private professional forums  not open for public viewing.  Only photos of the body parts (Breast, etc) are posted without identifying information such identifying  marks,  jewelry, etc.  and are always cropped/altered for privacy.         I have the right to request that any/all photos be pre-approved before posting on any social media  and will inform Colour Cosmetic Studio, inc.,  inc at time of service of my refusal to use any photos.  x_____  
  •  

  ACCEPTANCE:  

       Client Name ___________________________________________  

  • I have read all pages of this consent form and completely understand these risks listed above.     My questions have been answered. I DID NOT JUST SIGN THIS DOCUMENT. I read it in it's entirety.  x________________
  •  I certify that the information in the above questionaire and client intake /medical questionnaire is accurate and my questions have been answered.  I accept full responsibility for any complications that may arise or result during or following  the cosmetic procedure(s) to be performed at my request. x_________
  • I am 18 years of age or older with supporting documentation.  I will provide my drivers license or government Id at time of service regardless of my age.  X_________  
    • I understand that while Kathleen Cronin is a NYS Registered Nurse but that she is in no way performing my tattoo under her NYS Nursing license but rather under her Albany County License to Practice as a Tattoo Artist and that Colour Cosmetic Studio, inc is not a medical practice or medical spa.  All Tattoo procedures are regulated by:                                                                                 NYS Albany County  Body Art Licensing Services. X_______
  • The cost of my procedure and follow up visits have been explained to me. x___________
  • I agree to pay  $ ______________ .00    at the first session and this fee includes  (     ) appointments unless otherwise agreed  x_______
  • I understand that additional appointments  may be necessary to complete my desired outcome due to unforeseen skin, medical issues, medications, pigment retention, symmetry issues, improper pre or post care,  or any other issue (s) unbeknownst to me  or my tattoo artist at this time.  I understand that the cost of additional appointments is charged  a minimum of @$125  per 1 hour session, in increments of 15 minute,  plus $50 supply cost per session. X_________ 
  • I understand that cosmetic tattoo procedures are a process and that the follow-up appointments are important to the final outcome of my procedure and I agree to keep my follow-up appointments.  I further understand and accept that my work will be considered incomplete without these follow-up appointments. x____________
 
CLIENT (sign) _________________________________________________________Date______/_____/ 2017
 
Signature of  Technician ________________________________________________Date _____/_____/ 2017
Kathleen Cronin with Colour Cosmetic Studio, inc
1525 Western Ave., Suite 2
Albany, NY  12203
518-776-0067
www.colourcosmeticstudio.com  
Albany County Health Department  518.447.4620

 

 

 

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