BROWSZI STUDIOS PMU/TATTOO CONSENT RELEASE FORM

BROWSZI STUDIOS PMU/TATTOO CONSENT RELEASE FORM

Pre care •Must be 18 or older•Must not be pregnant orbreastfeeding• Must not have any type of activecancer.•Can not be scheduled forchemotherapy or in radiation.•Can not be on skin medications suchas Acutane•Avoid over the counter and prescription blood thinner medications such as advil and sleep medication 24 hours prior to appointment. •If on prescription medicationplease consult your doctor.•Avoid excess sun one week prior to appointment.•Avoid caffeine and alcohol at least 24-48 hours prior toappointment•No chemical peels or intense skin treatments such as any laser 6 weeks prior •DO NOT wax, thread, tweeze or tint brows 1 week prior to appointment •Avoid botox or filler at least ONE MONTH prior toappointment• Avoid taking fish oil or vitamin E oil at least 1 week beforeappointment.
I acknowledge by signing this release form that have been given the full opportunity to ask any and all questions might have about obtaining a tattoo from 1 acknowledge that all my questions have been answered to my full and total satisfaction I specifically acknowledge that have been advised of the facts and matters set forth below, and agree as follows
Print full name & DOB mm/dd/yyyy
I am not under the influence of alcohol or drugs.I do not have acne, freckies, moles, or sunbum in the area to be tattoced that might be agitated by the tattoo process healing excludedThave looked over my design, checked the spelling if applicable, and give my full consent to the application of my tattoo.I acknowledge that am not pregnantI acknowledge that am free of communicable disease.I acknowledge that have truthfully represented to the associates, agents and representatives of I am over eighteen (18) years of age.I do not have any history of hepatitis or jaundice within the last 12 monthsI am agreeing to the payment of ___________ for my service and acknowledge that if not my card is on file and I can be reported for theft is pbalance is not paid in full after procedure is completed.I have eaten with the past 4 hourso Have you ingested anticoagulants (such as heparin or warfarin), antiplatelet drugs, or nonsteroidal anti-inflammatory drugs (NSAIDS) (such as aspirin, ibuprofen, etc.) in the last 24 hours?o Have you ingested any medication that can inhibit the ability to heal a skin wound?o Do you have any allergies or adverse reactions to dyes, pigments, latex, iodine, or other such products?o Do you have hemophilia, epilepsy, a history of seizure, fainting, narcolepsy, or other conditions that could interfere with the body art procedure?o Do you have a history of skin diseases that might inhibit the healing of the body art procedure?o Do you have any communicable diseases (i.e., hepatitis A, hepatitis B, HIV, or any other disease that could be transmitted to another person during the procedure)?o Do you have diabetes, high blood pressure, heart condition, heart disease, or any other conditions that could interfere with the body art procedure?
I acknowledge it is not reasonably possible for the associates, agents and representatives of to determine whether might have an allergic reaction to the dyes, pigments. or processes used in my tattoo and agree to accept that such risks are possible.
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I acknowledge that infection is always possible as a result of obtaining a tattoo particularly in that event that do not take proper care of my tattoo. and have been advised of the signs and symptoms of infection that indicate a need to seek medical care. statement, If an adverse reaction or infection develops at the site of your tattoo, contact your personal physician for treatment and report to SNHD Special Programs at (702) 759-0677
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I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change. alter or remove my tattoo.I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions All questions about the body art procedure have been answered to my satisfaction
I acknowledge that the obtaining of my tattoo is my choice alone and consent to the application of the tattoo and to any actions or conduct of the associates. agents or representatives ofthat are reasonable necessary to perform the tattoo procedure. I agree to release and forever discharge and forever hold harmlessand its associates, agents officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by and its associates, agents and representatives in the future. Tacknowledge that tattoo inks. dyes and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown.
I acknowledge that the obtaining of my tattoo is my choice alone and consent to the application of the tattoo and to any actions or conduct of the associates. agents or representatives of that are reasonable necessary to perform the tattoo procedure.
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Body art can cause swelling, bruising, discomfort, bleeding, and pain; o Body art can cause allergic reactions; o Body art can cause irreversible changes to the human body; o body art has a risk of infection. o Any effective removal of the body art work may leave permanent scarring and disfigurement. • Patron evaluation section that asks at a minimum the following questions that evaluate Patron’s condition for receiving body art without violating their medical privacy. • The following statement: Consult a physician prior to the procedure if you have any concerns about any of the questions below:
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I agree to release and forever discharge and forever hold harmless and its associates, agents officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by and its associates, agents and representatives in the future.
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I acknowledge that there is a chance might feel lightheaded dizzy during or after being tattoced I agree to immediately inotify the practitioner in the event feel lightheaded, dizzy and/or faint before, during or after the procedure.
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I acknowledge that there is a chance might feel lightheaded dizzy during or after being tattoced I agree to immediately inotify the practitioner in the event feel lightheaded, dizzy and/or faint before, during or after the procedure agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense

have been fully informed of the risks of tattooing including but not limited to infection, scarring difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotica Having been informed of the potential risks associated with getting a tattoo, still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing if single-use presterilized equipment is used please provide Lot/ID number

Signature Procedure description
I agree to follow all instructions concerning the care of my tattoo, and that any touch ups needed because of my own negligence will be done at my own expense
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If I am getting a finger tattoo I acknowledge that it will fade faster than other tattoos, touch ups will be required more often and at my own expense.
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Signature

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Date

MonthDayYear
Date
Artist
Maggie Szi ( Browszi Studios )
Procedure description (Area on body/Size & design if tattoo) if PMU specify lip blush or brows please specify style & if it is a cover up (if you have previous work prior from another artist)
ID/DL #
Clients printed Full name
Clients Address
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