Intake Forms

INTAKE FORMS

Informed Consent to Procedure

                                                    

I am not pregnant or nursing

 

I am 21 years of age or older

 

If under 21 years of age, it is by law required to submit written consent from

all guardians prior to receiving a cosmetic or paramedical tattoo

 

I absolutely understand and accept that such procedure is a process, sometimes

requiring multiple applications of color to achieve desirable results and the 100%

success cannot be guaranteed.

 

Prior to the end of my procedure, the aftercare/post-procedure instructions

will be reviewed with me and I agree to follow them.

I will ask any and all questions that I may have pertaining to my

Cosmetic or paramedical tattoo prior to the actual service.

 

Depending on the procedure(s), which I select, I accept responsibility for

agreeing upon the shape, and position of the cosmetic or paramedical

tattoo.

 

I understand that the color selection and color results in all procedures are

not an exact science.

 

I understand that positioning of my procedures can be affected if I elect

cosmetic surgery, Botox or Restalyne and I assume this responsibility.

 

If I am a contact lens wearer, I realize that I must remove my contacts prior to my eyeliner procedure.

 

I understand that overtime the pigment in my procedure will fade and this determines that it is a time for a color refresh appointment. Typically, color refresh appointments are performed between 1-3 years of the initial procedure.

 

I realize this is an elective cosmetic procedure and is not medically

necessary.

 

I am aware that that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling, or fever blisters on the lip area following lip procedures.

 

I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my laser technician of my cosmetic tattoo and to stay a finger length away from the area.

At first sign of infection, we advise you to consult your physician, and then notify your cosmetic tattoo technician.

 

I understand and accept that there are no refunds for the services performed at Trucco Skin

Photography and Videography Release

 

 

I hereby authorize my practitioner and its representatives at Trucco Skin to use or publish photographs and/or videos of me either provided to them by me or taken on their premises at or at such other locations where services are or were performed by representatives of Trucco Skin.

 

I understand and agree that these materials will become the property of Trucco Skin and will not be returned.

 

In consideration for the use of said photographs or videos I agree that I will receive no financial compensation. 

 

I hereby irrevocably authorize Trucco Skin to edit, alter, copy, exhibit, publish or distribute said photographs or videos for purposes of publicizing Trucco Skin’s services and/or products or for any other lawful purpose.  In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears.  Additionally, I waive any right to royalties or other compensation arising or related to the use of the photographs.

 

I hereby hold harmless, release and forever discharge Trucco Skin and its representatives from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

 

I am 21 years of age and am competent to contract in my own name.  I have read this release before signing and I fully understand the contents, meaning and impact of this release.

Microneedling Consent

 

Microneedling is a treatment which intentionally needles the skin to the outermost layer of the skin, which triggers the body’s own natural response to remodel skin texture, and create collagen and elastin production in the skin. Microneedling has shown to reduce the visibility of acne scars, fine lines, and wrinkles, diminish hyperpigmentation, and improve skin tone and texture, resulting in smoother, firmer, younger-looking skin. Microneedling treatments are performed in a safe and precise manner with sterile, disposable, single use implements and are normally completed within 30-60 minutes.

 

Although the majority of patients do not experience any complications with microneedling, it is important to understand the risks involved. Microneedling is a minimally invasive treatment which utilizes micro needles to create minor, superficial open channels in the skin. Because there are open micro channels in the skin after the treatment, it is important to keep the treatment area clean and free of bacteria. Precautions to take are to change pillowcase, disinfect phones and eyewear, Do not touch treatment area for 24 hours.

 

I understand that if not properly cared for, the treatment area may get infected.

 

It is recommended that makeup not be applied for 24 hours after the treatment.

 

I understand that there is no way to guarantee or predict the results for the treatment I am receiving today, or future treatments.

 

I understand that multiple treatments in conjunction with at home skincare is recommended to achieve optimum results.

 

If outdoors, I will apply sunscreen that is at least SPF 35 or greater 30 minutes prior to sun exposure.

 

In rare cases, allergies and sensitivities have been reported after treatment.

 

I understand that if I have every experienced a fever blister at any time in my life, that the virus associated with it can be activated with Microneedling if performed on or around the lip area. Taking an anti-viral will aid in treating an outbreak.  

Pigment (Tattoo) Lightening

 

The technicians at Trucco Skin specialize in color corrections of cosmetic tattoos that have faded to an undesired color overtime, as well as cosmetic tattoo removal/lightening for unwanted pigment in the brows and lips. Cosmetic ink has made tremendous advancements in recent years, however, ink from years passed may require special attention and care to achieve a modern, updated look.

 

In most cases, undesired pigment tones can be corrected, as long as the shape not a concern with a color correction.

 

With saline tattoo removal solution, we can adjust the shape, to achieve a look that is flattering. In some cases, tattoo removal is the best choice.

 

Saline tattoo removal involves tattooing a specialized, safe and natural, saline solution over and into your existing tattoo. The solution lifts the existing pigment molecules from the skin by the process of osmosis. A scab will form, which further lifts the previously placed pigment. The number of sessions needed depends on the saturation and size of your tattoo.

 

Generally, with a few treatments, you will see significant results.  Some tattoos will be removed with just one or two treatments.  The treatment is repeated until the tattoo fades to your desire, or is gone.  Immediately after the treatment, it is normal for the skin to be red and irritated, which will dissipate within 8 weeks. For your comfort, a topical anesthetic (lidocaine) is applied to the treatment area before the tattoo removal process.  

 

Your permission is necessary before commencing any treatments. The permission form is intended to be a tool to ensure that you have been informed about your procedure, the risks and benefits, and to provide you with a chance to ask questions.

 

  • I understand that the success of cosmetic tattoo removal varies greatly depending on the age of the tattoo, the pigments originally used, and the saturation of pigment colors.
  • The number of treatments varies from client to client and depends on your previous cosmetic tattoo procedure. Most commonly 2-6 treatments are necessary to remove the pigment.
  • I understand that there is no guarantee that the removal procedure will remove all the pigment.
  • I understand that a shadow/skin stain of the tattoo may be present after the treatments.
  • (If client has scars from previous procedures or removal) I understand that my skin was originally scarred by the cosmetic tattoo or removal application needle. This injury may remain even if all the pigment is removed.
  • I understand that my skin will be extremely sensitive to sunlight following the procedure. I agree to refrain from the sun or tanning for 2 weeks prior and 4 weeks following the treatment. Maximum SPF should be worn at all times.
  • I understand that I must wait 8-12 weeks between removal sessions in order to give my skin adequate time to heal.

The nature and method of the proposed pigment (tattoo) lightening procedure has been explained to me including risks and/or possibility of complications during or following its performance.  I understand there may be a certain amount of discomfort or pain associated with the procedure and that the other adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and swelling.  Fever blisters may occur on the lips following lip procedures in individuals prone to this problem, it is required to take an antiviral if susceptible to fever blisters.  Secondary infection in the area of the procedure may occur, however if properly cared for, this is rare. 

 

I understand that several treatments may be needed in order to attempt to achieve my desired results.  However, I have not received any guarantees to the quality of the outcome of the process.

 

I understand there are laser options available for pigment (tattoo) removal.  I have decided to decline those methods for the time being.

 

I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen.  Scarring, hyper-pigmentation or hypo-pigmentation, discoloration or other damage to the skin may occur during this process and may be permanent. This is rare but it can happen.  I will not hold my technician, Trucco Skin Clinic and/or the distributor/manufacturer of tattoo removal products used in this attempted pigment (tattoo) lightening or removal liable for any damages that may occur to my person.

 

I understand there will be no refunds if the desired lightening result is not achieved.

 

Fitzpatrick Skin Type Scale:

 

  1. Always burns, never tans
  2. Always burns, sometimes tans
  3. Sometimes burns, always tans
  4. Rarely burns, always tans
  5. Moderate levels of melanin in the skin
  6. High levels of melanin in the skin

 

For skin types 5 and 6; I understand that I am at a higher risk for hyper-pigmentation and hypo-pigmentation than other skin types. I agree to the risk involved.

 

I understand that lightening tattoo pigment is difficult, if even possible.  As a result, I will not hold my technician or Trucco Skin Clinic responsible for any resultant failure to lighten the unwanted pigment.          

 

I agree to follow all aftercare instructions provided by me by my technician.                                                

There is a fee for this service and additional fees for all additional sessions. The fees have been explained to me and I agree to the fees listed on Trucco Skin’s website. 

 

I have read and understand this agreement and all my questions have been addressed and answered to my satisfaction. I consent to the terms of this agreement

Use of ALL Acne Medications (Topical or Oral Form)

 

It’s important to understand that using acne medications in topical or pill form are contraindications in Cosmetic Tattoos. Although creams may not be applied directly to the treatment area, they can travel up to 2 inches under the skin. If taking a pill for your acne, there is no way of knowing how it will affect the skin. However, knowing they are used in treatments of skin conditions, they can, may or will affect the results.


Due to the chemicals/acids found in these products the pigment can appear blurry under the skin, change in color, fade prematurely, cause the skin to bleed or not retain at all. These are all potential risks that you accept can or will happen.


After the procedure is healed and you resume using the above-mentioned products (creams/pills), they will still impact the longevity of the procedure.


If you are on a pill form of acne medication and do not discontinue use, we have no way of knowing the outcome of your procedure.


NO guarantees have been made to me as to the final results.
I fully understand above said risks & wish to proceed with the procedure.


If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.

 

I take full responsibility & accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Auto Immune Release Form (Alopecia)

 

I understand that Alopecia is an auto-immune disease and is a contraindication for Cosmetic Tattoos.  Due to the change in texture of the skin and lack of follicles, the pigment CAN & may heal more solid/powdered.  The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all.  These are all potential risks.

 

NO guarantees have been made to me as to the final results.

 

I fully understand and accept the above said risks and will not hold Trucco Skin nor their associates accountable if above said risks occur. 

 

Follow up perfecting appointments will be scheduled at the standard 6–8 week mark even if the above risks occur and are at discretion of the technician.  Standard follow up fees will apply if the above risks occur.

 

All services performed are non-refundable.

 

I fully understand above said risks & wish to proceed with the procedure.

Auto Immune Addendum

 

I understand that having an auto-immune disease is a contraindication to cosmetic tattoos.  Due to the illness/disease and the medications taken to treat the illness or disease, the pigment can and may heal more solid/powdered.  The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all.  These are all potential risks.

 

I understand that several paid follow-up appointments will be necessary to achieve color saturation, and still may not hold completely. Your technician can not foresee the final outcome of your treatment. Patience and commitment, as well as, realistic goals for the patient is vital in order to move forward with the treatment. 

 

NO guarantees can be made to me for the final results.

 

I fully understand above said risks & wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Excessive sun exposure or tanning beds

 

I understand that excessive sun exposure, or using tanning beds pre or post procedure is a contraindication to cosmetic tattoos.  Skin in this condition may be prone to bleed during the procedure, may heal darker than the intended color, and may fade to an ashy color as the tan fades.  In addition, the pigment may heal more solid/powdered, hair stroke technique may appear thicker then intended, or appear blurry under the skin, fade prematurely, or not retain at all.   These are all potential risks you accept may happen.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks & wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility & accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Fitzpatrick 1 & 2 Skin Types

(Red heads and Strawberry Blondes)

 

 

I have been informed that having a Fitzpatrick skin types of a 1 or 2 (natural born red head, dark red, light red, red undertones, and strawberry blonde) can and may cause the pigments to fade prematurely, look more blurred or powdered under the skin, the hair strokes can appear blotchy and spread, change in color or not retain at all. Typically, one or two more perfecting appointments are necessary to achieve the final results. We as technicians, have zero control over your skin or how it heals.

 

In addition, Fitzpatrick 1 or 2 with red hair tendencies have a different tolerance for pain because their skin’s pigment-producing cells lack the function of a certain receptor and may affect the activity of endorphins. Lack of this receptor function causes changes that tip the balance between pain sensitivity and pain tolerance.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks & wish to proceed with the procedure.

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Frequent Exercise/Working Out

 

I understand that high impact frequent exercise (3+ days a week or more) can and will cause the hair strokes or other areas of your cosmetic tattoo to appear blurry under the skin, change in color, fade prematurely or not retain at all.   Due to the sweat (salt) that your body produces this will impact the result.  We use Saline (salt) to remove or lighten pigment, as a technique and procedure.  Even after the results are healed sweat will still impact the longevity of the procedure.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks and wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Menopause Heat & Sweats

 

I understand that having a body temp that runs hot is a contraindication for Cosmetic Tattoos.

 

Due to the heat that your body produces, and the sweat that occurs, the pigment may heal more solid/powdered.  The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. 

 

These are all potential risks and you accept that may happen.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks and wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Oily Skin, Large Pores, Accutane

 

I understand that having oily, severely oily skin, or large pores are contraindications in Cosmetic Tattoos.  Due to the over-production of the oil glands in the skin & the size of the pores, the pigment may heal more solid/powdered.  The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all.   These are all potential risks you accept may or can happen. We recommend our “powder fill / ombre brow in these cases.

 

If you were previously on Accutane, the skin integrity has changed. There is a higher chance that the pigment will not retain, fade rapidly or change in color. It is required to be off Accutane for a minimum of one (1) full year before receiving any procedures at Trucco Skin.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks and wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Patch Test Consent

 

A patch test is required for any client with a history of allergies or sensitivity to makeup, perfumes, dyes, tints, metals or has sensitive skin in general. The client is responsible for informing the technician of any and all allergies and skin sensitivities prior to their procedure.

 

Patch testing involves breaking/scratching the skin, usually behind the ear, and placing a small amount of product on that area. The test site must remain undisturbed for a minimum of 24-hours; client to monitor the area for 24-72 hours for any reaction.

 

At the first sign of a reaction or irritation such as swelling, itching, burning, redness, etc… immediately cleanse and rinse the test sight thoroughly, seek immediate medical attention, and inform your cosmetic tattoo technician.

 

Ingredients used in pigments for cosmetic tattoos vary by manufacture and may contain but are not limited to iron oxide, titanium dioxide, isopropyl alcohol, glycerin and ethanol.

 

Topical anesthetics may contain but are not limited to lidocaine, tetracaine, benzocaine and epinephrine.

 

If you have allergies or sensitivities to any of the aforementioned ingredients, please advise your technician prior to your procedure as you will be required to have a patch test one week prior to your procedure date. Please email truccoskin@gmail.com, no later then 1 week prior to your procedure date to schedule your patch test.

 

I consent to the patch test and release Trucco Skin and their associates, from any and all liability related to any allergic reaction as a result of this test. I have been informed that reactions can occur at any time in the future. Sun exposure can also cause a reaction with the pigments. I understand that a favorable patch test, i.e., no adverse reaction to product(s) tested, does not guarantee I will not have a reaction at the time of the procedure, and/or at a later date.

 

If you wish to waive the patch test and release Trucco Skin and their associates, from any liability if I develop an allergic reaction to the cosmetic tattoo pigments and/or topical anesthetics during or after my procedure(s). I have read this document in its entirety and understand and agree to the conditions.

Previously Done Cosmetic Tattoo

 

I have been fully informed and understand that having cosmetic tattoos previously done by another technician will impact my results of this current procedure.

 

Due to other unknown pigments, techniques, and placement on the treatment area, your current technician is limited to how they can achieve your desired result.

 

This is an attempt to correct a procedure that was originally done by another technician and absolutely no guarantees have been made to me as to the final result.

 

No guarantees have been made to me as to the final results.

I fully understand above said risks and wish to proceed with the procedure.

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Use of Retinols, Salicylic & Lactic Acid

 

I understand that using anti-aging products containing retinols, salicylic, lactic acid, alfa hydroxy and the like are contraindications to Cosmetic and Paramedical procedures and tattoos.  Due to the chemicals/acids found in these products the pigment will not enter the skin properly and can appear blurry under the skin, change in color, fade prematurely or not retain at all.  These products also can cause bleeding.  If you bleed, the procedure may or will have to cease.  These are all potential risks that you accept can or will happen.

 

After the procedure is healed and you resume using the above-mentioned products, they will still impact the longevity of the procedure.  The creams and acids can travel up to 2 inches under the skin and will cause premature fading, blurring, color changes or no retention at all.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks and wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Piercing/Scar/Injury Trauma to Treatment Area

 

I understand that having a scar or injury in the area where the cosmetic tattoo is being performed is a contraindication of the procedure.  I fully understand that the pigment may fade prematurely, look more blurred or powdered under the skin, change in color, heal too dark or not retain at all.  The skin in an area with trauma may have indents, bumps, and or scar tissue, making it difficult for the skin to absorb the cosmetic tattoo pigments.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks and wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Trichotillomania (Pulling)

 

I understand that Trichotillomania/Pulling is a contraindication for Cosmetic Tattoos.  Due to the change in texture of the skin and scar tissue the pigment may heal more solid/powdered.  The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. 

 

It is vital to allow your treatment area to fully heal during the 6-8 weeks without touching, scratching, pulling, or peeling at the area. Doing so will impede the final healed results.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks and wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.

Vitiligo Auto Immune Release Form

 

I understand that Vitiligo is an auto-immune disease and is a contraindication to cosmetic tattoos.  Due to the change in texture of the skin and lack of follicles, cosmetic tattoos may heal solid/powdered.  In addition, hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all.  These are all potential risks.

 

No guarantees have been made to me as to the final results.

 

I fully understand above said risks and wish to proceed with the procedure.

 

If you do not accept the above-mentioned possible risks, it is recommended not to move forward with the procedure.

 

I have been informed of my risks, and I wish to move forward with my procedure. I will hold Trucco Skin, and their associates harmless if the above said risks occur.­­­­

 

I take full responsibility and accept that the above-mentioned risks could happen and is at no fault of the technician.

 

All services performed will be non-refundable and final. 6-8 week follow-up appointments will not be made any sooner if the above said risks occur and standard fees will apply.