If I have any concerns, I will address these with Katherine Booth, Licensed Master Esthetician. I give Katherine permission to perform the tinting procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I have accurately answered the intake questions, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult Katherine immediately.

I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above information and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the Katherine responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.