Cosmetic Tattoo
Disclosure & Release Agreement for Cosmetic Tattooing/Micropigmentation
Please read and fill out this "Disclosure & Release Agreement" completely, making certain that you understand all information provided, and that your information is correct.
You have the right to be informed so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure.
Please read and INITIAL the statements below to indicate:
I understand the following statement completely.
Your Initials
*
No food, drinks, or making/receiving phone calls are allowed in the procedure area. Minimal texting or email is fine as long as it doesn’t interfere with the procedure. (This applies to any guests of the client as well.)
Your Initials
*
No warranty has been made to me as a result of this semi permanent makeup procedure and the final result cannot be guaranteed.
Your Initials
*
There may be risk of infection if aftercare instructions are not followed.
Your Initials
*
I realize that there is a potential for discomfort during the procedure and during the healing process.
Your Initials
*
There is a possibility of bleeding, swelling, and allergic reactions to the pigments used.
Your Initials
*
Cosmetic tattooing is considered semi-permanent and will fade with time.
Your Initials
*
A tattoo can only be removed with surgical or laser procedures, and that any effective removal may leave permanent scarring or disfigurement.
Your Initials
*
Misplacement or migration of the pigment can occur, under rare circumstances, requiring excision and/or correction of the misplaced pigment.
Your Initials
*
My artist will not, under any circumstance, perform any procedures on me if I am known to have any allergies related to the products used. I understand this is my responsibility to know of an allergy and inform my artist of any allergies that may cause issues during or after the procedure. (Our pigments contain: sterile water, glycerin, isopropyl alcohol, iron oxides, titanium dioxide, chromium oxide)
Your Initials
*
I understand that I must inform my artist of any and all medication(s) I am currently taking.n (Pain control medications such as aspirin or ibuprofen may cause blood to thin, and excessive bleeding may occur during or after the procedure.)
Your Initials
*
I do not currently take Accutane and/or haven't taken it for at least 12 months.
Your Initials
*
I understand that it is my responsibility to advise the artist of any concerns I may have BEFORE they begin the procedure.
Your Initials
*
I am not under the influence of any drugs or alcohol.
Your Initials
*
I am not pregnant.
Your Initials
*
I am actually reading these and not just signing my initials.
Your Initials
*
I release the studio and its representatives and subsidiaries of all claims for injury, seen or unseen, that may occur as a result of this procedure.
Your Initials
*
I fully understand the questions, terms and conditions of this Disclosure & Release Agreement. I accept to waive my rights to any claim against the artist for any reason whatsoever.
Your Initials
*
I believe that I have sufficient information to give this informed consent.
Your Initials
*
I certify that this Disclosure & Release Agreement was completed by me and that all entries and information are true and complete to the best of my knowledge.
Description of tattoo
First & Last Legal Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Years Young
Phone Number
*
Please enter a valid phone number.
Drivers License #
*
Picture of Drivers License (.jpg or .png) - use your phone camera. ; )
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Artists Name
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: