• Scalp Micropigmentation Consent Form

    Scalp Micropigmentation Consent Form

  • Informed consent for scalp micropigmentation procedure

  • Date of Birth:*
     / /
  • Format: (000) 000-0000.
  • Select the following that applies to you*

  • Please read and initial each of the following:

  •    
    *   I understand the procedure is used to apply color and it's not a one-step procedure and requires subsequent visits to achieve desired results. Maintenance and touch-ups are scheduled as needed and may vary from six months to three years.

       I understand that within time, the pigment can and will settle and change the color according to metabolism, skin type, age, and exposure to the sun, smoking, alcohol, and medications.

    *   I recognize that my technician uses his/her experience and his/her professional advice for a natural look.

    *   I have received and acknowledged pre and post-procedure instructions and agree to adhere to such instructions strictly.

    *   I agree that before and after photos of my treatment are required for our records. This does not provide consent for use of the photos.

    *   I understand that within time, the pigmentation can, and will, settle and change color according to metabolism, and skin.

    *   Any alterations or adjustments after the second session do not fall under the guarantee.

    *   I acknowledge that I have truthfully presented to the associates, proper identification that states that I am over eighteen (18) years of age or that I have the authority to consent for a minor receiving the aforementioned treatment.

    *   I voluntarily allow Arch Angels NJ/NYC to be my scalp micro-pigmentation provider, and such association and technical assistance as they may deem necessary to perform on my scalp.

  • By signing this form, I indicate that, I read and agree to the terms and conditions of the booking, deposit and cancellation policy.

  • Photography and Publicity Release

  • Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to [legal entity/organization], its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities including the Internet This consent includes, but is not limited to:

    (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

    (b) Permission to use my name; and

    (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

  • This consent is given in perpetuity and does not require prior approval by me.

  • I hereby:*
  • Date*
     / /

  • The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.

  • Medical Health and History

  • Please select all conditions that apply

  • In signing below, I give my consent to proceed with the Scalp Micro Pigmentation treatment and confirm that I have read and agree to the terms and conditions and medical questionnaire [in advance or on the treatment day and] with sufficient time to understand its contents.

  • Video Surveillance Disclosure & Consent

    Notice of Electronic Monitoring
    In accordance with New York Labor Law § 203-C and applicable New Jersey privacy statutes, Arch Angels NYC & NJ utilizes video surveillance on these premises to ensure the safety of patients, staff, and visitors, as well as to protect company property.

    • Scope of Monitoring: Cameras are located in public areas, hallways, entrances/exits, and designated areas.
    • Privacy Protections: Surveillance is strictly prohibited and not conducted in areas with a high expectation of privacy, including restrooms, changing rooms, or employee locker rooms.
    • Audio Recording: In compliance with state wiretapping laws and "one-party consent" regulations, video surveillance in some areas is conducted without audio recording to maintain the confidentiality of patient-provider communications.
    • Purpose: These recordings are used solely for security, safety, and quality assurance purposes.

  • HIPAA Compliance: Photo/Video Storage & Extraction

    Storage and Security of Digital Media
    Any video or photographic footage that captures a patient’s likeness or identifies their medical condition is treated as Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA).

    • Secure Storage: All digital media is stored on encrypted servers with restricted access. Access logs are maintained to track who views or extracts footage.
    • Retention Policy: Recordings are retained for a period of 90 days, after which they are permanently deleted or de-identified, unless required for an ongoing investigation or legal proceeding.
    • Transmission: Any extraction of video for external use (legal requests, insurance, or transfers) will be performed using secure, encrypted channels.
    • Patient Rights: You have the right to request an accounting of disclosures regarding your recorded image, provided the footage has not been routinely destroyed per our retention policy.
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