SMP Consent Form

Scalp Micropigmentation Consent Form
Informed consent for scalp micropigmentation procedure
Date of Birth:*

MonthDayYear
Date
Full Name:*
Address:*
Age:*
Phone #*
Email Address:*
example@example.com
Referred by:
Select the following that applies to you*

AlopeciaSMP RereparationSMP Follow UpMale Pattern BaldnessLong HairScar CamouflageThinning HairHair Transplant ScarsOther
Please read and initial each of the following:
Signature*   I understand the procedure is used to apply color and it's not a one-step procedure and requires subsequent visits to achieve desired results. Maintenance and touch-ups are scheduled as needed and may vary from six months to three years.

Signature   I understand that within time, the pigment can and will settle and change the color according to metabolism, skin type, age, and exposure to the sun, smoking, alcohol, and medications.

Signature*   I recognize that my technician uses his/her experience and his/her professional advice for a natural look.

Signature*   I have received and acknowledged pre and post-procedure instructions and agree to adhere to such instructions strictly.

Signature*   I agree that before and after photos of my treatment are required for our records. This does not provide consent for use of the photos.

Signature*   I understand that within time, the pigmentation can, and will, settle and change color according to metabolism, and skin.

Signature*   Any alterations or adjustments after the second session do not fall under the guarantee.

Signature*   I acknowledge that I have truthfully presented to the associates, proper identification that states that I am over eighteen (18) years of age or that I have the authority to consent for a minor receiving the aforementioned treatment.

Signature*   I voluntarily allow Arch Angels NJ/NYC to be my scalp micro-pigmentation provider, and such association and technical assistance as they may deem necessary to perform on my scalp.
By signing this form, I indicate that, I read and agree to the terms and conditions of the booking, deposit and cancellation policy.
Client Signature*

Clear

Photography and Publicity Release
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to [legal entity/organization], its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities including the Internet This consent includes, but is not limited to:

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name; and

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.
This consent is given in perpetuity and does not require prior approval by me.
Name*
I hereby:*

Consent to the use of my image and likenessDo not consent to the use of my image and likeness
Signature*

Clear
Date*

MonthDayYear
Date
The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.
Signature of Parent or Legal Guardian

Clear

Scalp Micropigmentation Consent Form

Informed consent for scalp micropigmentation procedure

Please read and initial each of the following:

By signing this form, I indicate that, I read and agree to the terms and conditions of the booking, deposit and cancellation policy.

Photography and Publicity Release

Medical Health and History