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Revive Medical Tattooing & Body Piercing
4021 Calloway Dr. Suite 600/700 Bakersfield CA 93312
Treatment Consent Form
Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Please upload a copy of your ID or Drivers License.
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Browse Files
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PHOTO ID
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Health History
Do you have any allergies (e.g., medications, latex, pigments)? Please list them.
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Do you have any medical conditions such as diabetes, high blood pressure, autoimmune diseases, or heart conditions? Please list all medical conditions.
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Do you have an allergy to glycolic acid, vitamin C, hyaluronic acid, jojoba oil, borage oil, or rice bran oil? If the answer is yes, please list them.
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Are you currently pregnant or nursing?
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Please Select
Yes
No
Do you have any skin conditions (e.g., eczema, psoriasis, keloids,prone to hyper pigmentation, or other scarring tendencies)? Please list them.
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Do you have any history of cold sores, especially if undergoing treatments around the lips?
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Please Select
Yes
No
Have you had any recent surgeries in the area to be treated?
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Please Select
Yes
No
Are you currently taking any medications or supplements, including blood thinners, antibiotics, or steroids? Please list ALL medications and supplements being taken.
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Do you have any history of cancer? If yes, please specify the type and any current treatments.
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Have you ever had any adverse reactions to pigments, tattoos, or other permanent makeup?
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Please Select
Yes
No
Do you smoke or use nicotine products?
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Please Select
Yes
No
Have you recently used any exfoliating or peeling products on the treatment area (e.g., Accutane, Retin-A, glycolic acid)?
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Please Select
Yes
No
Do you have any recent sunburn, tanning, or other sun exposure to the treatment area?
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Please Select
Yes
No
Are there any other health issues or concerns that might affect the treatment outcome or healing?
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By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes to the information listed on all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward the technician and "Revive Medical Tattooing & Body Piercing" for any injury or damages incurred due to my misrepresentation of my health history.
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Treatment Goals and Expectations
Do you understand that results vary from person to person?
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Are you aware that multiple sessions may be required to achieve desired results?
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I understand that while treatments can significantly improve the appearance of scars, stretch marks, and areola areas, no treatment can completely remove scars or stretch marks. Additionally, I acknowledge that the color of pigments used in 3D areola tattoos and scar/stretch mark camouflage may change or fade over time.
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Yes
I understand that this treatment involves a non-surgical procedure with risks that may include infection, skin reactions, changes in pigmentation, scarring, and others.
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Yes
I acknowledge that results may vary and are not guaranteed.
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Yes
I understand that all sales ar final and the the services rendered are non-refundable. I waive my right to request a refund or chargeback through my bank.
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I understand and agree
Model Release and Photography Consent
I understand that my before and after photos may be used for promotional purposes, including social media, websites, and educational materials.
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I understand
I consent to the use of these photos without identifying personal details, such as my face or name, unless I explicitly give further consent.
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I consent
I do not consent
I understand that I will be asked for weekly photos during the healing process. These photos will also be used for promotional purposes if consent has been given on this form.
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I understand
Precare and Aftercare
https://docs.google.com/document/d/1KyyXGqElupfpgQFokLaCi7uWUrypziOmBYRWfLx_tA0/edit?usp=sharing
I have received and reviewed the pre-care and after-care instructions in writing. (FILE HAS BEEN ATTACHED ABOVE)
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Yes
I understand that failure to follow these instructions may affect my results and that any required corrections may incur additional costs.
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I understand
Release of Liability
I understand that I should contact a doctor immediately if I show any of the following symptoms of infection. Signs and symptoms of infection, including, but not limited to, redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.
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I understand
I acknowledge that I have been informed that tattooing, body piercing, and permanent cosmetic procedures involve permanent changes to the skin. Tattoos and permanent cosmetics are considered forms of body art and are permanent in nature. I understand that tattoo inks, dyes, and pigments have not been approved by the U.S. Food and Drug Administration (FDA) and that the health consequences of using these products are unknown. I further acknowledge that infection, scarring, allergic reactions, and other complications may occur as a result of receiving body art services. I accept full responsibility for any such outcomes and consent to proceed with the procedure
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I, the undersigned, hereby release and hold harmless Revive Medical Tattooing & Body Piercing and its representatives from any and all claims, damages, or liabilities arising from my decision to undergo permanent makeup, scar and stretch mark camouflage and revision services, 3D areola tattoos, or any other treatments provided. I fully understand the nature of these procedures, including the potential risks, side effects, and outcomes. I confirm that I have disclosed all relevant medical history and received aftercare instructions. By signing below, I acknowledge that I am choosing to proceed voluntarily and accept all associated responsibilities and risks
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Please Select
I agree to the above statement.
Signature
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Date Filled Out and Signed
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Month
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Day
Year
Date
All information gathered from the client that is personal medical information and that is subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or similar state laws shall be maintained or disposed of incompliance with those provisions.
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