PERMANENT IMPRESSION COSMETICS
By; Kathleen Moreillon, C.M.I., R.D.H.

Photo of Drivers License needed. 

Date:_______________________________________

Name:__________________________________________________________________

Home Address:___________________________________________________________

City:______________________________ St:____________Zip Code:_______________

Home Phone:__________________________________________

Cell Phone:____________________________________________

Web Address:____________________________________________________________

Disclosure and consent for permanent cosmetics and dermal procedures.

I, __________________________as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. You have described the recommended procedure to be used as Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin. Micro pigment Implantation is a form of tattooing used for the purpose of permanent cosmetics makeup and skin imperfection camouflage. I voluntarily request as my permanent cosmetic technician, Permanent Impression Cosmetics and such association and technical assistance as she may deem necessary to perform on my body the following procedure(s):

______________________________________________________________________

Please check one:

_____I hereby authorize Permanent Impression Cosmetics to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.

_____I hereby authorize Permanent Impressions Cosmetics to take photographs of the work performed both before and after treatment to be maintained only in file.

Please Initial what pertains to you:

______I understand that this description of the procedure is not meant to scare or alarm me. It is simply to make me better informed so that I may give or withhold my consent to this procedure.

______I have been informed that I am in good health and not under the care of any physician.

______I am not under the care of a physician.

______I am currently under the care of a physician.


I am being treated for the following conditions:________________________________________________________________________________________________________

Disclosure and Consent for Permanent Cosmetics and Dermal Procedures


______I hereby authorize the release of medical information to Permanent Impression Cosmetics and have signed the attached release form.

______I understand that no 100% warranty or guarantee has been made to me as to the results of the procedure because the results are determined in part by the nature of the pathology of my skin type but not limited to the following factors: A) Medication (Advise the specialist of any medication currently being administered), B) Skin characteristics: dryness, oiliness, sun-damage, thickness, color chemically-damaged and etc., C) My skin color blending with pigment colors, D) pH balance of my skin, which may change from visit to visit, E) Alcohol intake, smoking, etc., F) After care treatments G) Current state of health.

______I understand that there is a possibility of hyper pigmentation resulting from a procedure, especially in individuals prone to hyper pigmentation from a scar or other injury.

______I have been told that there may be risks and hazards related to the performance of the procedure planned for me.

______I understand that a certain amount of discomfort is associated with this procedure. It has been explained to me that the following possibilities may occur upon completion of the procedure: Minor and temporary bleeding, bruising, redness or other discoloration of the skin; swelling; fever blisters on the lip area following lip procedures in individuals prone to them; eyelash loss for eyeliner procedure, possible scarring, pigment migration, infection, allergic reaction to pigments, and/or fading or loss of pigment. It has been explained to me that I must defer from donating blood for one year after the procedure. I understand that I must inform the radiologist that I have iron oxide permanent makeup pigment if I am to receive a MRI (Magnetic Resonance Imaging).

______I have been told that the markings are permanent and there is a risk of infection following the procedure.

______I have been told that a follow up procedure may be required and that the color of pigmentation may fade.

______I have been told that there is a chance that I may experience a corneal abrasion from the eyeliner procedure.

______I have been told that there is a chance of allergic reaction to pigment and that my body may reject the pigment.

______I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and believe that I have sufficient information to give this informed consent.

______I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify Permanent Impression Cosmetics and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and Permanent Impression Cosmetics or the reach thereof, shall he settled by arbitrator(s) may be entered in any court having jurisdiction thereof.

______I understands that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Permanent Impression Cosmetics and the Indiana State Department Of Health.

______I agree that these waivers also pertain to and are designed to protect any and all establishments where Permanent Impression Cosmetics conducts business.


Failure to follow post-treatment instructions may cause loss of pigment, discoloration or infection.

Remember, colors appear brighter and more sharply defined immediately following the procedure, As the healing progresses, color will soften. Makeup may be used to tone color down until this time.

If necessity, an appointment for a touch up procedure may be made between 4 weeks to 6 months following the initial procedure at no extra charge.



IF YOU HAVE ANY QUESTIONS CALL Kathleen Moreillon at (317) 490-9069

Medical History Form

Are you now or have you been under the care of a physician within the last two years?__________________________________________________

If yes, Please provide reason, physician’s name, address and phone number. __________________________________________________________________________________________________________________

Person to contact in an emergency:

Name:_______________________________________________________

Address and phone:______________________________________________

List all medications, herbs, and vitamins you are currently taking, including Retin A, Glycolic Acid, and Acutane: ______________________________________________________________________________________________________________________

Have you recently undergone a skin peel?___________________________

Have you been told to be pre-medicated to get your teeth cleaned?___________________

If yes, why?_______________________________________________________________

Have you ever had a cold sore or lession on you lips or mouth?_________________ If yes, Permanent Impression Cosmetics will not perform a lip procedure without client taking medication. Get a Rx. from you physician for Valtrex or Zivirex, and take 500 mg. 3 days before and 3 days after procedure. I_________________________________,will take the medication above before any lip procedure.

Are you taking blood thinning anticoagulant medications? (Asprin, Ibuprofen, Coumadin, or Alcohol) _____________________________________________________
Do you use tabacco products?_______________________________________________
Are you pregnant or nursing?_______________________________________________
Are you taking birth control pills? _____________________________________________
Do you wear contact lenses?_______________________________________________
Have you had laser eye surgery?___________________________________________
Have you ever had any eye trauma?__________________________________________
Are you prone to eye infection?______________________________________________
Do you bruise or bleed easily?_______________________________________________
Do you have a hard time healing?____________________________________________
Do you use a sun lamp or tanning bed?_______________________________________
Please add any other illness or problems you have had in the past: ______________________________________________________________________ ______________________________________________________________________
Whom may I thank for referring you?__________________________________________________________________



Signature:______________________________________________________________

Date:__________________________________________________________________

Witness:_______________________________________________________________


Please circle any allergies you have:

Other allergies_______________________________________________

Circle any conditions you have ever had: