CONSENT TO PERMANENT MAKEUP APPLICATION RELEASE AND WAIVER OF ALL CLAIMS

I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent makeup from Kiran Chhetri Gyawali hereafter called “Technician” and that all of my questions have been answered to my full and total satisfaction.

Procedure to be performed:

I specifically acknowledge that I have been advised of the matters set forth below and agree as follows:

I acknowledge that obtaining permanent makeup is my choice alone, the application of permanent makeup will result in a permanent change to my appearance and that needles and inks will go into my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent makeup to the original condition, and it is very costly to remove.

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thin my blood.

I suffer from hepatitis or other risk factors for bloodborne pathogen exposure or any other communicable disease. I have informed the Technician of the fact and have been advised of any medications and procedures necessary to promote satisfactory healing.

I do not suffer from any medical or skin conditions such as but not limited to keloid or hypertrophic scarring, psoriasis at the site of the permanent makeup or any open wounds or lesions at the site of tattoo.

I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.

I have advised the Technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have an allergic reaction to the permanent makeup process and further acknowledge that such a reaction is possible.

I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol to my knowledge. I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have a tattoo at this time.

I acknowledge infection is always possible as a result of the permanent makeup application and I agree to follow all suggested instructions concerning the care of the permanent makeup site while it is healing.

I acknowledge and give consent to this permanent makeup studio to use images of my tattoos for marketing and/or publishing purposes in various media such as the internet, magazine, printed and/or television etc.

I understand that the permanent makeup site usually takes 2 weeks or longer to heal. I agree to release and forever discharge and hold harmless the technician, all employees, contractors, and the management of the permanent makeup studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo, and assume all responsibility for the decisions made consenting to this permanent procedure.

I am aware that permanent cosmetic inks, dyes, and pigments have not been approved by the federal Food Drug Administration and that the health consequences of using these products are unknown.

Medical Consent and Procedure Form