Consent And Release Agreement

CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETIC PROCEDURE
This agreement contract and all attached sheets are one agreement and all the information, clauses, and covenants in this agreement are incorporated in the attached sheets as though set out in full therein, however, if any clause, disclosure, or covenant in this contract shall differ or be in conflict with any and all attached sheets, this contract and its covenants shall govern. The undersigned permanent makeup/tattoo professional, hereinafter known as Releasee, hereby performs the implantation of pigment/inkless under the skin hereinafter known as the permanent cosmetic tattoo procedure(s) and the undersigned client, hereinafter known as the Releasor, or you, hereby receives the permanent cosmetic tattoo/tattoo procedure(s) subject to the terms and conditions herein set out:

The agreement to have a permanent makeup procedure and or tattoo performed is entered into by:
(Name of Releasor(client))*

First NameLast Name
Guardians Full Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Type of Service being performed:*

Fine Line TattooCamouflage TattooAdvance ISR TattooOmbre BrowsMagnetic tattoo removalPiercing
Procedure Site:*
Description of procedure: *
And with reference to the facts listed on the pages of this agreement: Therefore, for there considerations, the Releasee and Releasor agree as follows:
ACKNOWLEDGEMENT OF THE RISKS OR COMPLICATIONS ASSOCIATED WITH THE PERMANENT COSMETIC TATTOO AND TATTOO PROCEDURE/REMOVAL.
A. The Releasor has been informed by the Releasee of the possible dangers that may occur as a resultof having a permanent cosmetic tattoo and tattoo procedure performed. The Releasor acknowledges that those dangers may occur from stretchmark removal/scar camouflage/scar lightening/ombre brows procedure including injury from the permanent cosmetic, allergies from pigment used in the procedure(s), swelling, bruising (although rare), temporary minor bleeding, redness or pinkness, and soreness. The Releasor understands and acknowledges that the permanent cosmetic tattoo/ procedure may permanently alter the appearance of the Releasor's face/ procedure location of which may not be desirable to the Releasor.

B. Now, the Releasor having been fully and completely advised of all inherent risks, dangers, and complications which may arise from a permanent cosmetic tattoo procedure, voluntarily assumes all and any risks, dangers, or complications which may arise as a result of a permanent cosmetic tattoo procedure. To help minimize any risks, the Releasor will answer Yes or No the following conditions in order to describe if the Releasor has any of the following medical conditions:
MEDICAL CONDITIONS*

Do you suffer from keloid or hypertrophic scarring?DIEBETESAlcoholism or consumed alcohol in the past 24 hrs.?ELPILEPSYUNDER 18 YRS OLDAccutane or acne treatment in the past year?Do you use skin care products containing Retin-A, glycolic or alpha hydroxyl?HEMOPHILICAre you pregnant or breastfeeding?ACTIVE SKIN DISEASEAUTOIMMUNE DUSORDERHEPATITISBLOOD DISEASECHEMICAL PEELUSING GLYCOLIC ACIDOTHER TATTOOSHEART CONDITIONALLERGIES TO ANY MEDICATIONS OR TOPICAL SALVESTAKING MEDICATIONTaking blood thinners such as; Aspirin, Ibuprofen, Alcohol, etc. in the past 48 hrs.?ANY OTHER DISEASEUSING TANNING BED OR PRODUCTSANY RECENT LASER TO THE TATTOO AREAPLANNING COSMETIC SURGERYCURRENTLY UNDER DOCTOR CAREPLANNING ANY VACATIONHave you done Botox or Filler in last 4 weeks? *HIVCurrently are on or have been on antibiotics in the past 2 weeks?Blepharoplasty (Eyelid surgery)?Hepatitis (A, B, C, D)?Brow Lift?Easy Bleeding?Face Lift?Eye surgery/Injury/ corneal abrasion?Abnormal heart condition?Brow or lash tinting?Cancer?Have you ever tested positive for HIV or Hepatitis?Do you have a phobia of needles or suffer from fainting attacks?Brow waxing in the past 2 weeks?Do you have any skin infections or inflammatory problems (e.g. herpes, acne etc)?Difficulty numbing with dental work?Allergy to food, metals, soaps or cosmetics etc.?Any diseases or disorders not listed?Current list of medication or vitamins you're presently taking:None
Please list any medical conditions, issues, or medications not listed above:
I acknowledge that I have carried out one or more consecutive tattoo removal treatments with below treatment method in planned treated area.

RejuviAcidsSalineHome TreatmentLasersIf other please name itNONE
Please Name other tattoo removal service:
How many sessions done before?
IF YOU MARKED YES TO ANY OF THE ABOVE MEDICAL CONDITIONS PLEASE EXPLAIN:
When was the last time you ate?*
Please check if any allergies to the following ingredients:*

Coconut OilAvocado OilFrankincense OilSunflower OilAragon OilRosehip OilLavender OilVitamin EVitamin CGlycolicChamaecyparis Obtusa LeafExtractCoffee ExtractDryopteris CrassirhizomaExtractAspalathus LinearisExtract,NONE
For skin types V and VI; I understand that I am at a higher risk for hyper-pigmentation and hypo-pigmentation than other skin types. I agree to the risk involved.*
INTIAL ABOVE
I have been duly informed of the natures, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor*
INTIAL ABOVE
I acknowledge that I have received a copy of aftercare instructions after initial procedure and was verbally instructed by the technician.*
INTIAL ABOVE
I agree that all the above information is true and accurate to the best of my knowledge*

Clear
Date*

MonthDayYear
Date
Magnetic Tattoo Removal ONLY
If you are currently under a physician’s care for any condition, please describe:
I acknowledge that Magnetic Tattoo Removal is my choice alone. It will result in a permanent change to my appearance, and that needles and solution will work on my skin. No representations have been made to me as the ability to later restore the skin involved to the original condition
INTIAL ABOVE
I acknowledge and give consent to this Technician to use images of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed and or television etc
INTIAL ABOVE
I understand I will have Magnetic Tattoo Removal performed using appropriate instruments and sterilization techniques. I understand that the saline tattoo removal site usually takes 2 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors and the management of the permanent make-up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure and conduct used in my saline tattoo removal and assume all responsibility for the decision(s) made consenting to this permanent procedure.
INTIAL ABOVE
I accept FULL RESPONSIBILITY for any complications that may arise during or after the procedure and service provided, which is being performed at my request and approval.
INTIAL ABOVE
If you experience any signs or symptoms of an oncoming infection including, but not limited to: redness swelling tenderness of the procedure site, red streaks going from the procedure site toward the heart, elevated body temperature, or purulent drainage from the procedure site, YOU MUST SEEK MEDICAL CARE FROM A FAMILY PHYSICIAN OR MEDICAL PROVIDER AND NOTIFY THE ARTIST IMMEDIATELY
INTIAL ABOVE
I acknowledge having carried out one or more consecutive tattoo removal treatments and my skin may have invisible scars.

acknowledge
I understand there will be no refunds if the desired Removal result is not achieved.
INTIAL ABOVE
Signature

Clear
Possible Risks, Hazards or Complications:
Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. Lip procedures are more likely to involve some pain.

Infection: Infection is very unusual. The area treated must be kept clean and only freshly cleaned hands should touch the area. See "After Car" sheet for instructions on care.

Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. You follow up appointment will likely correct any uneven appearance.

Asymmetry: Every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness.

Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice pack may help and the bruising and swelling typically disappears with 1-5 days. Some people don't bruise or swell at all.

Eye Exposure: There is a small risk of eye injury when an eyeliner procedure is performed. To avoid corneal abrasion, Celluvisc, a thick eye drop is used to protect the eye prior to the procedure. Eye drops are used to cleanse and flush the eye after the procedure is complete.

Anesthesia: Topical anesthetics are used to numb the area to be tattoos. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form the typically use. If you are allergic to any of these please inform me now.

MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low-level magnet may be requires if you need to scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.

Fever Blisters: If you are prone to cold sores or fever blisters, (herpes simplex), there is a high probability that you will get them. It is advised that you call your doctor for a prescription antiviral to help prevent this from occurring.

Allergic Reaction: There is a small possibility of an allergic reaction. If you would like to TAKE a patch test you have to wait 5-7 days to see if you get a reaction.

If you would like to WAIVE the test you take full responsibility for any allergic reactions and agree and forever discharge and hold harmless the technician, all employees, contractors, and the management of the permanent make up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo procedure, and conduct used in my tattoo and assume all responsibility for decision made consenting to this permanent procedure.

HIPPA Requirement: Any medical information obtained will be subject to the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Tattoo Inks: Tattoo inks, dyes, and pigments that have not been approved by the Federal Food and Drug Administraction have health consequences that are unknown.
Patch Test
The Releasor agrees to waive or to take a 6-week patch test prior to the permanent cosmetic tattoo procedure*

Waive patch testTake patch test
Agree:*

The Releasor agrees to accept full responsibility for the COLOR, SHAPE, AND THICKNESS of each and every procedure that the Releasor will have performed by the Releasee which is to include but not limited to the eyeliner, eyebrows, Stretch mark, scar camouflage, breast re-pigmentation, tattoo, and/or beauty mark permanent cosmetic procedure(s).
Agree:*

The Releasor agrees that in the event of a controversy between the Releasor and the Releasee involving a claim in tort, the parties shall resolve their dispute through small claims court.
Agree:*

The releasor certifies that he or she has read the following provisions of the Nevada Civil code Section: “A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the doctor.”
Agree*

The Releasor agrees that in the event that the Releasor prevails in a judgement against the Releasee, the Releasor agrees that the Releasor will not be entitled to a settlement that exceeds the amount paid for the work accomplished by the Releasee.
Agree:*

The Releasor acknowledges receipt of pre-procedure information and post-op care instructions, has read them, has been verbally told them, understands them, and agrees to adhere to them in order to help prevent secondary infection.
CONSENT FOR PERMANENT COSMETIC AND/OR TATTOO PROCEDURE
The Releasor fully and voluntarily consents to have the release perform the permanent cosmetic procedure(s) and is fully aware and informed of all and any inherent risks, dangers, and complications that may occur as a result of the procedure(s) as described in this agreement. The Releasee has reviewed the medical history of the Releasor and all questions of the Releasor have been satisfactorily answered by the Releasee.
RELEASE OF ALL CLAIMS*

In order for the Releasee to perform any permanentcosmetic procedure on the Releasor for which the Releasee is volunteering tohave performed after having been fully informed of all dangers and risksinvolved as described in this agreement including but not limited to swelling,allergy to pigment, pain, infection, redness, soreness, injury, and itching.
In order for the Releasee to perform any permanent cosmetic procedure on the Releasor for which the Releasee is volunteering to have performed after having been fully informed of all dangers and risks involved as described in this agreement including but not limited to swelling, allergy to pigment, pain, infection, redness, soreness, injury, and itching. I Releasee, voluntarily request that the Releasee performs such procedure(s) and I, for myself, my respective heirs, assigns, administrators, personal representatives, and next of kin, hereby will forever release and hold harmless the Releasee, The Beauty Plug San Diego LLC, and all Management, their affiliates, officers, members, agents, employees, other participants, and sponsoring agencies from and against any and all claims, damages, or liabilities that may result from the permanent cosmetic procedure(s) as described in this agreement including costs of medical care that may arise from the procedure including post-op care. The Releasor acknowledges that no other claims or guarantees have been made by the Releasee other than is expressly written in the agreement. In witness whereof both parties, the Releasor and the Releasee enter into this agreement by their signatures below on the date opposite their names
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in the procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approve the material given to me and I authorize Patricia Henson, as my permanent cosmetic technician to perform on my body the following procedures.*

Clear
Date*

MonthDayYear
Date
Front of Driver License *

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Back of Driver License *

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Consent and Release Agreement for Permanent Cosmetics

This form is designed to give information needed to make an informed choice of whether to undergo a permanent cosmetic application. I you have questions, please don’t hesitate to ask.

Although permanent cosmetic tattooing is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch up after the healing is completed.

Initially the color will appear much more vibrant or darker compared to the result. Usually within 60 days the color will fade 10-50%, soften and look more natural. The pigment is permanent but will fade somewhat over time and will likely need to be touched up through the years.
PHOTOGRAPHER'S/VIDEO MODEL RELEASE

For a consideration mutually agreed upon, and received by me for posing for photographs and/or video(s)hereto, I the undersigned to hereby assign to you the copyright and/or the right to copyright such photography and the right of reproduction thereof, either wholly or in part, an unrestricted use thereof in whatever manner of you or your license sees or assignees may, in your or their absolute discretion, think fit for all or any advertising. medical teachings, or other purposes whatsoever including the right of necessary retouching and tinting or workup for reproduction purposes.
(Customer or Guardian signature)*

Clear
(date)*

MonthDayYear
Date
If you are the parent or legal guardian of the above named Releasor, then please complete the following:
I Guardian Namerepresent that I am the parent or legal guardian of the above named Releasor, have read the full agreement including the above Recitals and give my full permission to execute this agreement on the Releasor's (minor's) behalf.
(Signature of parent or guardian)

Clear
(date)

MonthDayYear
Date
Guardianship Paperwork Upload

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CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETIC PROCEDURE

ACKNOWLEDGEMENT OF THE RISKS OR COMPLICATIONS ASSOCIATED WITH THE PERMANENT COSMETIC TATTOO AND TATTOO PROCEDURE/REMOVAL.

Magnetic Tattoo Removal ONLY

Possible Risks, Hazards or Complications:

Patch Test

CONSENT FOR PERMANENT COSMETIC AND/OR TATTOO PROCEDURE

If you are the parent or legal guardian of the above named Releasor, then please complete the following: