First Name*   Last Name*   
Street Address   Address Line 2  
 City   State   Zip   
Area Code*  
 Phone Number*   

AGREEMENT
  1. ACKNOWLEDGEMENT OF THE RISKS OR COMPLICATIONS ASSOCIATED WITH THE PERMANENT COSMETIC TATTOO PROCEDURE.

A. The Releasor has been informed by the Releasee of the possible dangers that may occur as a result of having a permanent cosmetic tattoo procedure performed. The Releasor acknowledges that those dangers may occur from stretchmark removal/scar camouflage/scar lightening 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:

1. Keloid      Yes   No      
2.Diabetes     Yes   No   
3.Alcoholic    Yes   No   
4.Epilepsy     Yes   No   
5.Under 18 yrs.   Yes   No   
6.Using Accutane   Yes   No      
7.Using Retin A   Yes   No      
8.Hemophiliac    Yes   No      
9.Pregnant or nursing    Yes   No      
If yes, then you cannot move forward w/ procedure at this time.
10.Active Skin Disease   Yes   No      
11.Autoimmune Disorders    Yes   No      
12.Hepatitis   Yes   No      
13.Blood Disease   Yes   No      
14.Chemical Peel   Yes   No      
15.Using Glycolic Acid   Yes   No      
16.Other Tattoos    Yes   No      
17.HeartCondition   Yes   No      
18.Allergies to ANY (medications or topical salves such as Bacitracin, Lanolin, Novocain, Metals, Neosporin, Paba, Rubber Gloves, Latex, Lidocaine, Epinephrine, Tetracaine, Benzocaine, Avocado, Coconut, frankincense, rosehip, sunflower?)   Yes   No   
If yes, Please List
     

19.Taking Medication    Please Select Yes No    if yes, please list below
   
20.Blood Thinners   Yes   No      
such as Aspirin, Coumadin, Alcohol or Ibuprofen?
21.Planning cosmetic surgery?   Yes   No      
A.The Releasor agrees to waive or to take a 6-week patch test prior to the permanent cosmetic tattoo procedure.
   Initial to waive patch test
    Initial to take patch test
B.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, and/or beauty mark permanent cosmetic procedure(s
C. 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.
D. The releasor certifies that he or she has read the following provisions of the California Civil code Section 1542: " 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."
E.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. F.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