Scalp Micropigmentation Consent Form
Camouflage SMP, LLC.
Client Information
Full Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
FEMALE ONLY: Pregnancy or Nursing?
Yes
No
Do you have a communicable disease?
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
I understand that this procedure is a semi-permanent change to my scalp and give permission to the SMP technician to do the procedure.
I allow my SMP to be photographed and be used for Camouflage SMP portfolio showcased with no identifiable features or personal information.
I acknowledge that Camouflage SMP does not offer refunds.
I agree that the technician does not have a way of identifying if I am allergic to the pigment or ingredients that will be used for my tattoo.
I understand that I need to take care of the SMP by following the instructions given to me by the Camouflage SMP.
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking good care of pigmented area.
I indemnify and hold harmless Camouflage SMP against any claims, expenses, damages, and liabilities.
I confirm that the information I provided in this document is accurate and true.
Signed Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Signature
Submit
Should be Empty: