INK HDZ Scalp Micropigmentation Consent Form

1
Email* This field is required.Enter a valid email
example@example.com
2
Name* This field is required.Enter your full name below
First Name
Last Name
Preferred Nick Name
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Cost of Procedure* This field is required.Enter the amount agreed upon from estimate or invoice below. If you are a model, enter “Model”.
5
Non-Refundable* This field is required.I understand this procedure is non-refundable (Initial below)
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6
Emergency Contact* This field is required.Enter name below
7
Emergency Contact Phone
Please enter a valid phone number.
8
If I am experiencing any of the following symptoms: FEVER, FATIGUE, DRY COUGH, or DIFFICULTY BREATHING, I will let my technician know at least one week before my appointment in order to reschedule.* This field is required.
I agree with the above statement and will inform my tech in order to reschedule
9
I affirm that neither I, nor any of my household members have experienced the symptoms listed above within the last 14 days.* This field is required.
I affirm
No, I have experienced symptoms and need to reschedule
10
I affirm that neither I, nor any of my household members, have been diagnosed with COVID-19 within the last 30 days.* This field is required.
I affirm
No, I have been diagnosed within the last 30 days and need to reschedule
11
I affirm that neither I, nor any of my household members, have knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.* This field is required.
I affirm
No, I have been exposed and need to reschedule
12
I understand that this business cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.* This field is required.
I affirm
I do not agree and thereby will not be getting treated by INK HDZ SMP
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By signing below, I agree to each of the above statements and release this business (INK HDZ SCALP MICROPIGMENTATION) from any and all liability for the unintentional exposure or harm due to COVID-19.* This field is required.* This facility agrees that they abide by the same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.
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14
Please select any of the following conditions that apply as they could prevent or delay the procedure from commencing* This field is required.
TB
HIV
Herpes
Diabetes
Skin Conditions
Eczema/Psoriasis
Pregnant/Nursing
Fainting/Dizziness
MRSA/Staph Infections
NONE OF THE ABOVE
15
Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?* This field is required.If yes, please list below. Otherwise, answer no.
16
Do you use any medications that might affect the healing of the Scalp Micropigmentation you wish to receive?* This field is required.If yes, please list below. Otherwise, answer no.
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Do you have any other medical or skin conditions that may affect the outcome of your procedure?* This field is required.
YESNO
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Do you have a history of herpes on the procedure site?* This field is required.
YESNO
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Are you on blood thinners?* This field is required.If I am currently taking blood thinners, I understand that I may need to reschedule my appointment for 4 - 6 weeks, depending on how recently I have used blood thinners to ensure they are out of my system before undergoing Scalp Micropigmentation.
YESNO
20
Are you currently on any antibiotics?* This field is required.If I am currently on antibiotics, I understand that I may need to reschedule my appointment for 4 - 6 weeks, depending on how recently I have used blood thinners to ensure they are out of my system before undergoing Scalp Micropigmentation.
YESNO
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Is there any information/medical conditions you feel you should provide to your SMP artist?* This field is required.If yes, please list below. Otherwise, answer no.
22
I affirm that all of the medical answers above are true* This field is required.Sign below
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23
The process used to implant pigment into the skin is not a one-step process. Hues of pigment are tattooed into the skin over multiple visits, with a minimum of a 10 days between each visit/session. While the pigment simulates the exact natural hair color and tone desired, it will not always be a perfect match. This is due to the fact that the natural skin tones vary due to temperature, sun exposure, varying blood circulation, etc. Pigments are permanent and do not change tone as it is injected in the top portion of the dermis. Because Scalp Micropigmentation is applied in the same manner as a tattoo, it carries with it possible complications and consequences associated with this type of treatment including but not limited to: infection, scarring, inconsistent pigment tone, pigment migration, and/or allergic reaction to the pigment. It is imperative that you do not expose the treated area to direct sunlight, tanning booths, or any products that increase melanin production. This is particularly critical during the healing process. We recommend the use of sunscreen on your completed treated area once the skin has healed (30 days after final session). This will assist in maintaining the integrity of the treated area. If you are contemplating other procedures on the treated area please be advised that such procedures may adversely affect or alter your results. It is your responsibility to check with your physician or technician when contemplating additional procedures. Some of these potential adverse changes may not be correctable. INK HDZ SCALP MICROPIGMENTATION is not responsible for changes which may occur to your treated area as a result of any other treatments provided elsewhere.* This field is required.
Yes, I agree
No, I do not agree and will NOT be receiving treatment from INK HDZ SMP
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I hereby grant INK HDZ SCALP MICROPIGMENTATION permission to use my before and after photos and/or videos in any and all of its publications, including web-based publications, without payment or others considerations. I understand and agree that all photos will become the property of INK HDZ SCALP MICROPIGMENTATION and will not be returned. I hereby irrevocably authorize INK HDZ SCALP MICROPIGMENTATION to edit, alter, copy, exhibit, publish, or distribute photos and/ or videos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photos/ videos. I hereby hold harmless, release, and forever discharge INK HDZ SCALP MICROPIGMENTATION from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrations, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM OVER THE AGE OF 18, OR, IF I AM UNDER THE AGE OF 18, HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT(S)/GUARDIAN(S) AS EVIDENCED OF THEIR CHECKING THE BOX BELOWNOTE: If you are a model, please select first box below.* This field is required.
Yes, I agree
No, please blur my photos
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How did you hear of INK HDZ SMP?* This field is required.
Google
Yelp
Instagram
Facebook
Tik Tok
Friend/Family
Other
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Date* This field is required.Enter today's date below
Date
Year
Month
Day
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I affirm that all the information in this consent form is true and is legally binding:* This field is required.Sign below
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