CAMOUFLAGE / PARAMEDICAL PROCEDURE

Please fill out the following table with a tick to indicate if any of the following relate to yourself.

Please fill out the following table to indicate if any of the following relate to yourself.

ACCEPTANCE: I have read and understand these risks listed above and they have been explained to me one by one. I DID NOT SIMPLY SIGN THIS DOCUMENT WITHOUT READING IT. I certify that the information in the above questionnaire is accurate and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request . I hereby waive and release, indemnify, hold harmless and forever discharge, its employees and owners from any responsibility and/or liability regarding any services and treatments.

By signing below, I acknowledge, understand and agree that:

• the staff at The Medical Tattoo do not practice medicine, does not accept health insurance, and have made no representation to the contrary.
• the information provided on this form is accurate and complete to the best of my knowledge, and that The Medical Tattoo is not responsible for complications or problems arising from any incorrect or omitted information;

some individuals will have complications related to semi-permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold The Medical Tattoo and its employees and contractors harmless for same;

• the staff at The Medical Tattoo will use the information provided above to assess my suitability for the proposed micropigmentation services.