The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for but may occasionally occur.By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:(Please initial the line next to the number after you clearly understand each statement) 1. initial I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible. 2a. initial I have previously had areola/scar micropigmentation performed by someone other than The Medical Tattoo on the same area that I am asking The Medical Tattoo to work on today.
YES NO
2b. initial IF YES, I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which The Medical Tattoo has no control. I understand that additional appointments after the initial and follow-up appointments may be required, and will be billed at The Medical Tattoos standard rates. I understand that The Medical Tattoo cannot predict the results in advance and can not guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold The Medical Tattoo harmless from same.3. initial I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my areola/scar tattoo, and that I must inform any future service provider that I have had micropigmentation applied. I understand and accept that such changes are not the fault of The Medical Tattoo or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further micropigmentation procedures. 4. initial I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.5. initial I acknowledge that obtaining the areola/scar tattoo is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of The Medical Tattoo and its employees and contractors reasonably necessary to perform the procedure.6. initial I understand that I will have the opportunity, within the time constraints of my appointment, to approve the design and color of the areola/scar tattoo to be applied, and I accept responsibility for same.7. initial I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of The Medical Tattoo.8. initial [Optional/Requested] I consent to The Medical Tattoo using “before & after” photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting The Medical Tattoo, which will then discontinue use of said photo(s).9. initial I have been given the full opportunity to ask any and all questions which I might have about obtaining areola/scar tattoo procedures from a micropigmentation specialist at The Medical Tattoo, and that all of my questions have been answered to my full and total satisfaction.If you have previously had micropigmentation performed by The Medical Tattoo, has your medical history changed since you last filled out The Medical Tattoo Medical Profile form?
I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. I hereby release and forever discharge and hold harmless The Medical Tattoo and its owners, managers, employees and affiliates from any and all claims, damages or legal actions arising from or connected in any way with my micropigmentation, or the procedure and conduct used in performing my tattoo, to the fullest extent allowed by the law.