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Online Consent Form

-I understand that there is a chance that I may experience a corneal abrasion (eyeliner procedure)

-Other risk involved with the procedure may include but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction(s) to products applied during and after the procedure fanning or spreading of pigment (pigment migration), fading of color and other unknown risk.

-I accept full responsibility for nay and all, present and future, medical treatments and expenses i may incur in the event i need to seek treatments for any known or unknown reason associated with the procedure planned for me.

-I acknowledge the procedure(s) to be performed and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.

-I understand that this is a cosmetic tattoo and with time pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, and use of chemicals such as Retin-A and Glycolic acids, touch-up maintenance work will be expected in the future to keep looking fresh.

-I understand that there is No Refund policy on permanent makeup. For some reason if my pigment does not stay or needs more touch-ups I agree to contact LRS for further discussions on additional applications. However, I am fully aware that refunds will not be issued.

-Payment is rendered upon completion of the session. In the unlikely event of a dispute, I agree to arbitration.

-I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify LRS, and I further agree that any controversy or claim arising out of or relating to the consent and/or any signed contract between myself and LRS or the breach thereof, shall be settled by arbitration in the award rendered by the arbitrator(s) may be entered in nay court having jurisdiction thereof.

-I understand that if I have an infection, adverse reaction or allergic reaction the procedure I must notify LRS a healthcare practitioner, Georgia Department of Health, drugs and medical devices division 1-888-839-6676.

-I certify that I have thoroughly read this form and or it has been read to me. I understand it's contents.

-I understand that I must follow post procedure instructions. Post procedure and aftercare will be given to each client at the end of each procedure.

-I have read and understand the contents of each item above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from or consequences of the aforementioned procedure(s) I further acknowledge that at the time of signing this consent to this procedure(s). I was of sound mind and capable of making independent decisions for myself and that no one has coerced me into making this decision. I also agree not to hold neither LRS, Teisha Reid and or anyone who may be assisting her liable for any reactions, outcomes, or occurrences that may or may not result from having the procedure(s).

What to Expect: Micro-pigmentation

-Permanent makeup will appear extremely intense and thick immediately after the procedure. The color will not look right the first few days. Other factors are added to the permanent makeup pigment bottles to counteract to undertones of facial skin. Browns can look orangish-brown, blonde brows may appear yellow, lip colors are shocking! Some colors initially look to bright and others look to dark, But don't worry... It changes. Excess pigment sheds off over the next 2-3 days, and then skin starts healing over. A layer of healed skin on top of the pigment masks and tones it down considerably. As swelling goes down the lines will be thinner. On about the fourth day you are close to looking normal and no one notices anything. Colors will continue to soften over the next few weeks. It will look very natural in 1-2 months.

What's normal with permanent makeup?:

-Treated area will flake

-When applying ointment pigment will come off on the q-tip

-After the first procedure permanent makeup will appear to be thinner.

-Everyone's body chemistry is different. Depending on anti-aging products used, sun exposure, smoking habits, prescription medication, skin texture, skin complexion, and or immune system some pigments may fade more than others. If your permanent makeup fades, lightens and or is nonexistence please do not panic. You have a touch-up and at this touch-up modifications can be made to adjust the procedure to your situation. Please note ***Permanent makeup is at least  2 step process. Therefore, loss of pigment is normal with some individuals.

-If you are having a permanent lip color procedure and you have ever had a cold sore you may have another outbreak. It's important that if you are prone to cold sores that you take valtrex at least 3 days before your appointment and another 3 days after. deep in mind over 70% of the US is infected with the cold sore virus so you may have the virus in your system and are unaware.

-Final healed result is at about 1-2 months. UNDER NO CIRCUMSTANCE WILL YOU BE ALLOWED TO GET A TOUCH UP BEFORE THIS TIME. If a touch up is needed, it is not done any sooner than 1 month after the first procedure. Performing a touch up to early could cause scarring and permanent damage to the treated area.

Select list conditions you have ever had in the provided area on the form below:

Artificial Heart Valves/Vasc.

Graft

Abnormal Heart Conditions

Anaphylaxis

Blood disease

Cancer

Low Blood Pressure

Liver Disease

Stomach Ulcers

Tuberculosis

Chemotherapy/Radiation

Hepatitis

Nervous Problems

Organ Transplant

Prolong Bleeding

Rheumatic/Scarlet Fever

Respiratory Disease

Psoriasis

High Blood Pressure

Epilepsy


Thyroid Disturbances

Cold Sores/Cancer Sores

Artificial Joints

Aids/HIV Positive

Anemia/Hemophilia

Atopic(allergy prone) Kidney Disease

Herpes

Glaucoma

Stroke

Tumors/Growth/Cyst Cancer

Prosthetic Hip or Joint

Fainting

Heart murmur

Psychiatric Care

Shingles

Skin Rash Circulatory Problems

Diabetes

Pacemaker Heart Surgery

List any allergies you have or have ever had in the provided area on the form below:

Latex

Nickel

Lidocaine

Novocain

Benozocaine

Tetracaine

Epinephrine

Antibiotic Ointment (Bacitrine)

List all medications you are currently taking, including Retin A, Glycolic Acid and Acutane in the provided area on the form below:

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Medical History form


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