Fill out form below for consent for your follow up session

Or you can send view paper form packet here located on the last page. Form can be scanned and emailed to CristalWalkerBeauty@gmail.com prior to your appointment

Name

First Name

Last Name

Phone

(###)

###

####

Medical history update

Has anything changed since your last session/visit? Please list any new medications and/or health issues. If no changes please put NO

COVID Vaccine

Have you gotten your vaccine in the last 2 weeks or plan to receive vaccine within 2 weeks of touch up session? Please include date of vaccine/s

I authorize Cristal Walker for my elective permanent cosmetic touch up procedure

This procedure is for cosmetic purposes only and I understand that the permanent cosmetic procedure carries with it the possibility of complications and consequences associated with their specific type of procedure. Including the risk of infection, scarring, eye damage, inconsistent color, hemorrhage, possible spreading, fanning or fading of the pigment and or allergic reactions to products used. Contingent upon any complication I understand that my artist and technician may call the service due to any reason and will do so for my protection and the integrity of my skin. I authorize my artist and technician and trust them to do whatever is necessary in these circumstances. I also understand that this cosmetic procedure is not guaranteed.

I fully understand that this permanent cosmetic procedure is not an exact science but rather a specialized art and that there is the possibility of unforeseen conditions arising. I fully am aware, accepting and have been consulted about my permanent cosmetic procedure and accept the permanency of the procedure as well as any of the possible complications.

please initial

Procedure can not be done on compromised skin surfaces listed below.

sunburn

rash

open lesions

acne

current infections

antibiotics 2 weeks before appointment

blood thinners week of (unless medically necessary)

non apply/all clear

I am not pregnant or nursing

please initial

I am aware and understand that the use of active ingredients in my home care can alter the results of my permanent cosmetic procedure. The use of acne, anti aging, pigmentation or condition based products with ingredients such as AHA, BHA, Benzoyl peroxide, enzymes, Bitmain A or Retinol/RetinA, over the counter or pharmaceutical grade ingredients or certain topical creams/ moisturizers prescribed by a dermatologist is not allowed, they can and will alter my final results. All active ingredients in the form of lotions, moisturizers of any form must be discontinued for up to 30 days before and after permanent cosmetic procedure.

please initial that you understand

Have you used Accutane in the last year

I certify that I have read, fully understand the Pre-Treatment and Post-Treatment instructions for my touch up procedure.

Name and date below I certify that I have agreed to follow them. I certify that I have read and understand the complications that can arise as a result during or following the touch up procedure and are acceptable to me. I have provided my artist with accurate and truthful accounts of my skin and medical history. I have read, and fully understand this touch up procedure, its complications and have consented for this cosmetic procedure to be performed on myself. This elective treatment is performed at my request according to this consent.

You can provide any extra information or concerns here