In Clinic Consent Form

Name *

First Name

Last Name

I present to Woven Ink that I am over the age of 18 and desire Claire Smith to perform the elective Cosmetic Tattoo procedure, understanding that this procedure is for cosmetic purposes only. If any unforeseen conditions arise in the course of this procedure calling for your judgement for procedures in addition to, or different from those now contemplated, I further request and authorise you to do whatever necessary in the circumstances. I am aware that NO GUARANTEES HAVE BEEN MADE TO ME CONCERNING THE RESULTS OF THE PROCEDURE. *

Yes

I also understand that a Cosmetic Tattoo Procedure can carry possible complications, risk of infection, scarring, eye damage, inconsistent colour, bruising, and possible spreading and fading of pigments, if instructions explained at the time of treatment and home care information are not followed. I understand the actual colour of the pigment may change due to blacks turning a dark blue or grey and due to the tone and colour of my skin. I fully understand as with all such procedures that this is not a science but rather an art. I request the cosmetic tattoo procedure, appreciating and accepting the permanency of the procedure can differ from person to person whether it last for months, years or forever as well as the possible complications with few known allergic reactions and consequences of the said procedure. *

Yes

I understand the implanted pigment will last approximately one to five years depending on which area the procedure was for. Tattooing longevity varies depending on my skin type and after care. *

Yes

The colour will not remain at the same intensity and darkness as when it was when first created. Maintenance touch ups will be necessary from six months onwards to keep the pigment looking fresh. Fees for maintenance visits will apply. *

Yes

I understand that if I do not follow up the second treatment within 1-3 months then an extra charge will apply to obtain the intensity of colour and shape required *

Yes

I understand that if I have had a prior cosmetic tattoo treatment done elsewhere and I then choose to have the procedure re -done, corrected or removal by Woven Ink. that there will be absolutely no claim against Woven Ink arising from such remedial treatment. *

Yes

I understand that I cannot exercise or sweat for a minimum of 7 days after my initial procedure and that I need to avoid sun exposure and sunbeds two weeks prior to my procedure *

Yes

I understand that with time the pigment will gradually fade. The length of time it takes to fade depends on my skin type, age, metabolism, medication, smoking, alcohol, sun exposure, Retin A and Glycolic Acids and any problems experienced with the implantation and absorbency into my skin. *

Yes

I understand that the treatment is very intensive and I accept that there may be crust formation on the brows, some initial swelling and possible bruising. *

Yes

I acknowledge that I have been given and have availed myself of the opportunity to ask any questions relating to the treatment and that any questions which I have asked were answered to my satisfaction. I am in good health and have no knowledge of the contraindication stated in the history form. If I do I have had medical clearance by way of a letter from my doctor. *

Yes

It is obligatory for the purpose of our documentation of procedures that I consent to the taking of before, during and after photographs of myself showing the Cosmetic Tattoo procedure. *

Yes

I authorise Woven Ink to use any photographs of myself for social media or advertising purposes deemed necessary. *

Yes

I understand that if I have any skin treatments, chemical peels, laser/IPL, cosmetic injections, plastic surgery or other skin altering procedures, it may result in adverse changes to my cosmetic tattoo treatment. I acknowledge some of these potential adverse changes may not be correctable. *

Yes

I CERTIFY THAT I HAVE READ AND INITIALLED THE ABOVE PARAGRAPHS AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND I ACCEPT FULL RESPONSIBILITY FOR THESE AND /OR ANY OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE COSMETIC PROCEDURE WHICH IS TO BE PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT WERE FILLED IN BEFORE I SIGNED THIS STATEMENT. I FURTHER AGREE THAT THESE PERMIT AND CONSENT FORMS ARE CONFIDENTIAL AND REMAIN THE SOLE PROPERTY OF Woven Ink. *

Yes