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KD Kaesthetics Online Consent Form

Disclosure and Consent for Tattoo 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 been described the recommended procedure to be Micropigmentation, the process of implanting pigment into the dermal layer of skin. Micropigmentation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.

I voluntarily request my Paramedical Tattoo Artist, to perform the following procedure(s): 

PLEASE READ AND CHECK ONE:

I authorize Keisha Davis to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)

  1. I understand the description is not meant to alarm me, just to make sure I’m better informed so that I may give or withhold consent for this procedure.

  2. I have informed KD Kaesthetics that I am in good health.

  3. I understand that no warranty or guarantees have been made to me as to the results.

  4. I understand that there is a possibility of hyperpigmentation resulting from a procedure,

  5. Especially in individuals prone to hyperpigmentation from a scar or other injury.

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

  7. I have been told that this procedure may involve discomfort or pain.

  8. I have been told that the markings are permanent and that there is a risk of infection

    following the procedure.

  9. I have been told that a follow-up procedure may be required and that the color of the

    pigment may fade.

  10. I have been told that there is a fee if a “touch up” is required.

  11. I have been told that there is a chance of an allergic reaction to pigment and that my

    body may reject the pigment.

Thanks for submitting!

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