Client consent Form

CLIENT CONSENT / MEDICAL FORM

Tattoo Removal Service
The following confidential medical information will be the property of Arch Angels NYC/NJ. This is required for the benefit and safety of the client in obtaining any and all procedures performed by Arch Angels NYC/NJ. Please read and fill out the information carefully. We hope your experience will be a pleasant one and we thank you for your cooperation.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ethnic Background (please include all nationalities)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Occupation
If we call you at home, do you want confidentiality?

Other

LIST OF ALL CURRENT MEDICATIONS

Rows	Msg. or Mcg	How Many per Day	Reason for Preascription
Name of Drug
Name of Drug
Name of Drug
Name of Drug

LIST OF ALL MEDICATIONS YOU TOOK IN THE LAST SIX (6) MONTHS THAT YOU ARE NO LONGER TAKING:

Rows	Msg. or Mcg	How Many per Day	Reason for Preascription
Name of Drug
Name of Drug
Name of Drug
Name of Drug

The client consents name* or waives their right to an allergy test prior to the permanent tattoo procedure to determine allergic or other reactions to the pigments being used by the Artist.
Special requests, concerns or remarks for artist
Signature of Client

PHOTOGRAPHY RELEASE CONSENT
We would like your permission to use these photos for advertising. For example, in portfolios, online and print ads, etc. Please be advised that no artist will be authorized to share your pictures on their personal social media accounts. Photos will only be publicized on the company's social media accounts. Your consent is necessary regarding this.
Please check the box and indicate if you would like your photos used or not regarding any and all advertising/marketing under Arch Angels NYC / NJ ONLY.
Signature
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.
By signing below, I acknowledge receipt of this written notice and consent to the use of electronic video monitoring as described above.
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.
By signing below, I acknowledge receipt of this written notice..

INFORMED CONSENT TO PROCEDURE

Please add Name
  First Name* I absolutely understand and accept that such a procedure is a process, often requiring multiple applications of color to achieve desirable results and 100% success cannot be guaranteed.

  First Name* I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them.
Depending on the procedure(s), I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color.

First Name* I understand that the positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restylane and I assume this responsibility.

First Name* If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.

First Name*I realize this is an elective cosmetic procedure and is not medically necessary.

First Name* It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment.

First Name*     I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, and removal of lines may or will turn permanent makeup dark or even black.

First Name* I agree to inform my esthetician or anyone operating such that I have permanent make up.

First Name* I give my consent to Arch Angels NYC + NJ to confer with my physicians for the medical information required for the safety of my procedures.

  First Name* I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner.

  First Name* I am aware that if an infection occurs after I have received Permanent Cosmetics to seek help from my primary physician or an emergency room, immediately.

  First Name* I am aware that the Final Sale is NON-REFUNDABLE.
Have you had COVID-19 vaccine?

Other
ACCEPTANCE AND ACKNOWLEDGMENT

I have read and understand these risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and my questions have been answered.

**Please read all questions thoroughly before signing**
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

CLIENT CONSENT / MEDICAL FORM

General Medical Questions

PHOTOGRAPHY RELEASE CONSENT

INFORMED CONSENT TO PROCEDURE