Cosmetic Tattooing

Medical History: Please circle and explain if you have ever had or currently have: Heart conditions, MVP, Pacemaker, Allergies to makeup, Accutane treatments, dry eye, Blepharitis, Keloid or hypertrophy scars, Diabetes, Strokes, Chest pains, Shortness of breath, Alopecia, Epilepsy, Seizures of any kind, Autoimmune disorders, refractive disorders, refractive eye surgery, Glaucoma, Hepatitis, jaundice, HIV, Joint replacement, Tendency to bleed excessively, Hyperpigmentation, Hypo-pigmentation, Ocular herpes, Hepatitis A, B, C, Gortex implants, High/Low Blood pressure, Neck/Back pain, Antibiotics before invasive procedure, Trichotillomania, Cancer (any time).

I understand and agree by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all my questions have been answered to my full satisfaction. I specifically understand and agree I have been advised of the facts and matters set forth below and I agree as follows:

I understand the nature of the procedure and understand that the procedure will result in a change in my appearance and that no representation have been made to me as to the ability to later change or remove result. I accept responsibility for determining the shape, color, and position of the pigment to be applied and understand that my skin color, texture, tone and history may modify the final color of the healed pigment.

RISKS

I understand that the known complications of micropigmentation includes: redness, swelling, puffiness, bruising, dry patches, tenderness, bleeding, infection, color loss, delayed wound healing. In addition to these potential risks, there may be other unpredictable risks.
I understand that it is not reasonably possible to determine whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used ill the procedure and agree to accept the risk that a reaction is possible.

RESULTS

I realize that my body is unique and understand that with time, pigment can fade and change color due to my metabolism, skin type, scar tissue, compromised skin, past and future medical treatments, current and future medications, my age, sun exposure, alcohol intake, smoking habits and Retin-A and Glycolic acids. I further understands that the practitioner cannot predict how my skin will react as a result of the procedure.
I understand that laser treatments, skin altering procedures, plastic surgery, implants, radiation and/or injections may alter and degrade my procedure results and that such change may not be correctable through further procedures. I further understand that such change are not the fault of the practitioner.
I understand that no guarantee has been made to me concerning the results that may be obtained from this procedure and that the professional recommendation is to aim for a natural look.
I understand that there are no warranties or guarantees, implied or specific about my outcome.

CONSENT
I have had the opportunity to explain my goal and understand which desired outcome are realistic and which are not. All my question have been answered, and I understand the inherent risks of the procedure I seek, as well as those additional risks and complications, benefits and alternatives.
I consent to be photographed and/or recorded before, during and after the procedure and consent to taking of before and after photographs and understand that such photographs and/ or recordings may be used for publication, education and marketing, I consent to the above, without expectations of payment to me now or in the future.
I do hereby release STRETCH MARK LAB, its agents and representatives from all liability in connection with the above.
I acknowledge that the obtaining of the procedure is by my choice alone, and I consent of the application of the procedure and to its attendant risks, and to any actions or conduct of the practitioner reasonably necessary to perform the procedure.

LIABILITY
I acknowledge that the practitioner is an independent contractor or lease space and is in no way affiliated with the doctor's office, hospital and/or tattoo studio in which tree practitioner performs the procedure and that I hold harmless the physician, office, hospital, facility and tattoo studio from all liability from the performance of the procedure.