Information Consent


LUXE Beauty Ink
Permanent Cosmetic Tattoo Artistry by Lynne
Greenburg Plaza
11825 SW Greenburg Rd., Suite 113
Tigard, OR 97223
503.805.3488

 

Thank you for taking the time to read and complete these forms prior to your scheduled appointment. I so appreciate you choosing LUXE Beauty Ink for your permanent cosmetic procedure and I’m confident you will enjoy the ease and beauty of your permanent cosmetics for many years to come!

 

Medical Chart – you will receive a separate PDF file (need to fill out and sign)

 

These look intensive and it’s a good amount of information to read through, but it should only take you a few minutes to actually fill the forms out, thank you!

 

PLEASE SIGN, SCAN AND EMAIL THESE FORMS BACK TO ME OR BRING ALL THEM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. IT WILL SAVE YOU TIME ON YOUR PROCEDURE DAY. You will also want to review the Pre and Post Procedure Instructions so you know what to expect with your permanent cosmetic procedure.

 

  1. Please fill out the top portion of each page
  2. Sign and date at the bottom

All forms are required and approved by the Society of Permanent Cosmetic Professionals (SPCP). These are standard forms within the permanent cosmetics industry. Please be precise and honest with your medical form indications, they contribute to valuable information on your process and recovery. Note that you are covered by client/patient confidentiality act and you may request a signed copy of your signed forms on the day of your visit. These forms are for your protection and you should always check the technician credentials for any procedures you have performed.

If you have any questions, please contact me at:

Lynne Sanders

503.805.3488

Thank you and I look forward to seeing you on the day of your appointment!

Please note that a 5 day notice of cancellation is required. We reserve a large amount of time out of our schedule for your procedure, and advance notice is greatly appreciated! Every attempt will be made

to provide the same courtesy notification should we need to reschedule your appointment due to illness

or unexpected emergencies.

 

LUXE Beauty Ink

Client Information Consent and Procedure Chart #1

Name:  

Address:  

City:   

State:   

Zip:   

Number:  

Date of Birth:    

Must be 18 yrs of age to have tattoo procedure, Drivers License or ID may be requested 

May I contact you at the locations below if necessary? 

 

Email:  

Employer:  

Occupation:  

Work Number:  

Procedure(s) Requested:   

The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. I understand that there are known and unknown complications and consequences associated with this type of cosmetic procedure, which include but not limited to: risk of infection, scarring, eye damage, hemorrhage, inconsistent color, possible spreading, fanning or fading of pigments and/or allergic reaction to any products used. Corneal abrasions are a rare side effect, and can be caused by rubbing or scratching my eyes or apply contact too soon after any eyeliner procedure. I understand that allergic reactions, although rare, are possible. I understand the actual color of the implanted pigment may modify due to the tone and color of my skin. I fully understand as with all such procedures that this is not a science but an art and that anything that can go wrong, may. I understand that this is a tattoo and I request the permanent skin pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences that can be associated with procedure.

 

I , present to Lynne Sanders and LUXE Beauty Ink, that I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and I desire the elective permanent cosmetic makeup procedure(s). I understand that this process is for cosmetic purposes only and not for any health related reasons. If any unforeseen conditions arise in the course of this procedure calling for her judgment for procedure in addition to, or, different from those now contemplated, I further request and authorize her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results or outcome of the procedure(s) or the number of treatments to achieve the desired appearance. I understand this can be a process and I must be in compliance with all aftercare instructions.

 

I , certify that I have read and fully understand this consent and procedure form. I initialed the above paragraphs as acceptance of terms and have a complete understanding of their significance. I accept full responsibility for the decision to have this cosmetic tattoo work performed.

LUXE Beauty Ink

Client Information Consent And Procedure Chart #2

I understand that if I have any skin treatments, such as but not limited to: Glycolic and other acid treatments, Micro-Dermabrasion, laser hair removal, laser or cosmetic plastic surgery, or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge that some of these potential adverse changes may not be correctable. I am aware that procedures, such as but not limited to: AlloDerm, Fat Transference, Dermagin, Silicone, other Alloplastic Implants or other injected substance into or around the lip tissue AFTER having lip liner or full lip color, may compromise the existing procedure boundaries.

 

I understand that the taking of before, during, and after photographs of the said procedure(s) are a condition of such procedure(s). I consent to them understanding they become the technician’s sole property thus giving Lynne Sanders permission to use for any purpose deemed necessary.

A patch test is available for color and possibility of allergic reaction to pigments however it does not ensure a client of absolute color or non-reactive action. If waived, I release the technician Lynne Sanders at LUXE Beauty Ink, from liability if I develop an allergic reaction to the pigment. (Pigment contents are: iron oxides, lakes, alcohol, glycerin and distilled/sterile water.)

I have received X , or I waived X a patch test:   

 

I have received a form on discussed fees and payment (page 4) and understand and agree with the arrangements made on that form. I have received a form and/or discussion on any/all pre and post procedure instructions and I will adhere to such instructions understanding that my failure to follow them may jeopardize my chances for a successful procedure.

 

Regarding any previous procedures:

  1. Approximate date(s) and type of procedure(s):   
  2. Do you have any information on: the pigments, color or machine used?:   

 

I, certify that I have read and fully understand this consent and procedure form. I initialed the above paragraphs as acceptance of terms and have a complete understanding of their significance. I hereby authorize Lynne Sanders perform the permanent skin pigmentation procedure(s). All explanations herein were made and all my questions have been addressed and answered. I accept full responsibility for any these and/or any other complications which may arise or result during or following my cosmetic procedure(s). I agree to be in compliance with all aftercare instructions. I filled in all questions, answers and consents before singing this statement and all other documentation. 

I understand that my consultation is prior to or on the day of my appointment. A consultation is an in person act or via telephone or electronic communication. I have had all my questions and concerns addressed. I understand all information as pertaining to my procedure as made binding by my signature below and this paperwork is part of my confidential client record (HIPPA). I understand that Lynne Sanders at LUXE Beauty Ink reserves the right to refuse service or re-schedule treatments for any reason deemed necessary.

 

Fees for Service

I understand there are no refunds for this elective procedure(s). I understand the cost listed below includes one (1) follow up (adjustment) visit six to eight weeks after the initial application, not to exceed six months from initial visit, preferably within 90 days. I understand it is my responsibility to schedule and complete my touch-up treatment. If touch up is not scheduled/completed within 6 months, the regular touch up visit price of $300 will be charged. Payment is due the day services are rendered at the first appointment. Accepted methods of payment are: Cash, Visa, MasterCard, Gift Certificate, or ATM card with Visa or MC logo. The use of a credit or debit card will include an additional 3% fee. All other arrangements must be approved of in advance. I understand that should additional visits beyond the first 2 visit be necessary, these will be at an additional cost. Occasionally additional visits may be necessary and Lynne will discuss this in full if this is the case. I understand that Lynne Sanders of LUXE Beauty Ink reserves the right to refuse service or to re-schedule treatments for any reason deemed necessary (ie, skin rash, infection, certain medications/health conditions, etc). I have read, understand and agree to the payment amounts and processes listed above, and I am indicating such by my signature below.

 

Prodedure(s):

Cash is the preferred method of payment. Please see below for additional methods of payment.

** I accept cards via Square or PayPal and I also use the Venmo App (ID is @Lynne-Sanders-4), and

   PayPal direct which are my preferred methods if not paying cash, PayPal ID is lynnesanders@comcast.net or 5038053488

** Please note that a 3% fee will be added to card purchases other than the initial deposit.*

 

$150.00 Non Refundable Deposit is required to reserve your appointment. This deposit will be applied toward your total due on the day of your first appointment. Please give 5-day notice if you are not able to attend your scheduled appointment or your deposit could be forfeited. When 5-day advance notice is given, deposit will move forward to rescheduled date. If advance cancellation notification is not given, payment in full may be required to reschedule and reserve a future day.

 

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Permanent Makeup in Portland Oregon http://luxebeautyink.com
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Document name: Information Consent
Unique Document ID: 8d21f2ef9ea53cb197a7e0e701c5887108d14dd8
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May 3, 2018 11:32 pm GMTInformation Consent Uploaded by Nicole Martinez - nicole@abrandnewbeauty.com IP 24.251.236.133