ADDRESS:

Date

Service

The following confidential medical information will be property of Issa SelfLove Oasis, LLC. This is required for the benefit and safety of the client in obtaining any and all procedures performed. Please read and fill out the information carefully. We appreciate your business!

NAME

Date of Birth

Date

Email

example@example.com

PHONE

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What form of contact preference: Email or Phone

Pick one

EmailPhone

TODAYS DATE

Date

PROCEDURE

PIGMENTS USED

HAVE YOU EVER HAD A FEVER BLISTER OR COLD SORE? Yes /No

IF YES, contact your physician for a prescription of ZOVIRAX or some other anti-viral medication.

I have read the above information regarding an anti-viral and understand its use is mandatory to reduce opportunity for sore break out, if I desire lip line or full lip color procedures.

Select one

YesNo

Signed Client

Print Client

Client Name

ARE YOU CURRENTLY UNDER THE CARE OF A PHYSICIAN? Yes/ No

Select one

YesNo

If YES WHY

Physician Name

Phone Number

Hepatitis

Aid Or HIV

Heart Condition

Ocular Herpes Diabetes

Stroke

Angina or Chest Pains

Allergies to Makeup

Kidney Disease

Accutane Treatment

Auto Immune Disorders

Dry Eyes

Asthma

Glaucoma

Hyper-pigmentation

Hypo Pigmentation

Any form of Cancer

Keloid or Hypertrophic Scars

Fill in any of the above conditions, if any pertain to you:

OTHER (If not noted in the above conditions) Please Specify:

Client Model Name

In consideration of my engagement as a model upon the terms stated, I hereby give to Photographer and Issa Selflove Oasis.

a) The irrevocable, exclusive and unrestricted right and permission to create, copy, use, re-use, alter, publish, License, assign and distribute the photographic portraits or pictures in which I may be included in whole or in part In conjunction with my own name, a fictitious name or no name at all. Photographer is granted the foregoing exclusive rights regarding the Released Images in any and all media now or hereafter known, including but not limited to film, print, video and digital reproduction for illustration, art, promotion, advertising, trade or any other purpose whatsoever. I acknowledge that as between Photographer and me, Photographer is and shall be the author of all Released Images under copyright laws and owns and shall own all Released Images.

b) I also permit and authorize the Photographer and any Authorized Parties to use any printed material or other materials or Media they desire with the Released Images.

c) I hereby relinquish any right that I may have to examine or approve: (1) the completed product or products or any Associated advertising copy or printed matter incorporating or associated with the Released Images, (2) any other Materials or media that may be used in conjunction with the Released Images, or (3) the use to which the Released Images may be applied.

d) I hereby release, discharge and agree to hold harmless the Photographer and all Authorized Parties. individually and jointly, from any liability to me or others associated with me by virtue of any blurring, distortion or alteration of the Released Images, or use of the Released Images in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said Released Images or in any subsequent processing, publication or usage thereof, Including without limitation any claims of defamation or violation of rights of privacy or publicity. I acknowledge and agree that this release and agreement to hold harmless shall continue indefinitely, regardless of whether any Released image used within the scope of this Agreement causes me in the future to feel embarrassed or otherwise injured in any

e) I hereby release, discharge and agree to save harmless the Photographer and any and all Authorized Parties from any Liability resulting from any injury or accident, regardless of cause, in which I am involved during a photo shooting.

I HEREBY AFFIRM THAT I AM AN ADULT OF LEGAL AGE AND HAVE THE RIGHT TO CONTRACT IN MY OWN NAME. I HAVE READ THE ABOVE AUTHORIZATION, RELEASE AND AGREEMENT PRIOR TO ITS EXECUTION; I FULLY UNDERSTAND THE CONTENTS THEREOF.

This agreement shall be binding upon me and my heirs, legal representatives and assigns. I, the undersigned model, assign to you the copyright photography.

Description of photographs: As compensation, I have received and expect no further compensation.

Client Models Name Please Print

CIIENT MODELS SIGNATURE

WITNESS

Client Models signature

DATE

Date

I have been informed of the risks, and possible complications resulting from permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: slight discomfort associated with procedure, infection, and scarring, inconsistent color, spreading, fanning or fading of pigments, slight bleeding & bruising. Individual prone to fever blisters may have outbreak if not properly medicated. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the undertone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. The Practitioner, makes no attempt too, or claim too, practice medicine. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s Initials

Signature of Client Model

Date

I, blanks ,recognize and acknowledge, that I have been given the full opportunity to ask Ms Iris Reyes any questions which I might have about the obtaining of any permanent cosmetic procedures from Issa Selflove Oasis and all associates. I also acknowledge that all of my questions were answered to my full and total satisfaction. I specifically acknowledge I have been advised of the fact and manners set below, and I agree as follows:

Initial

I am over the age of 18 and in sound mind, body, and health.I am not under the influence of drugs or alcoholI have received post procedure instructions and healing chart and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.

Initial

Should I have diabetes, epilepsy, hemophiliac, a heart condition, or any other medical or skin condition that can interfere with the application or healing of my Permanent cosmetic Tattoo I must reveal that information to my technician. I understand I must contact my doctor and bring a letter stating that it is safe to have my permanent makeup procedure.

Initial

I am not the recipient from an organ or bone marrow transplant or if I am I have taken the prescribed regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing permanent makeup or piercing.

Initial

I am NOT pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting my permanent cosmetics.

Initial

I recognize that it is not possible to determine if or whether I might have any allergic reaction to any of the topical preparations, pigments, dyes, used in the procedure; I understand and accept the risk that such a reaction is possible.

Initial

There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction, I release the technician from liability if I develop an allergic reaction to the pigment.

Initial

I understand that complications are possible when receiving permanent makeup procedures, particularly in the event that post-procedural instructions are not followed.

Initial

The Practitioner or any of the Practitoners associates cannot predict how my skin may react as a result of my procedure.

Initial

I understand that the permanent make up procedure may result in a permanent change to my appearance and that no representations have been made to me as to the ability to change or remove the result.

Initial

Skin altering procedures, such as plastic surgery, implants, and/or injections may alter or degrade my permanent cosmetic procedure. It has been explain to me that such changes are not the fault of the practitioner or any of the practitioners associates. I further understand that such changes may not be correctable through further permanent cosmetic procedures.

Initial

I consent to the admittance of authorized observers to the procedure.

Initial

I am consequential damages which result or arise from the application of my Permanent Cosmetic tattoo, whether caused by negligence or fault of the Practioner in Issa Selflove Oasis.

Initial

I consent to the application of the procedure and understand its attendant risks.I have reviewed and understand all the information given to me. I understand this is a contract and that I have received no warranties or guarantees with any of my procedures I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.

Clients Signature

Date

Witness Signature

Date

PLEASE TYPE INTO BOX BELOW IF YOU HAVE A HISTORY OF ANY OF THE FOLLOWING CONDITIONS:

CLIENT RELEASE FORM/PHOTOGRAPH COPYRIGHTS

PERMANENT MAKEUP MEDICAL RELEASE