I agree to the use of Digital Electronic Signatures on this form below. I understand that all of my answers will be electronically sent to Michelle Lynn and be digitally logged as a legal representation of my agreement to the terms set forth:

YES, I agree to the use of electronic signaturesI DO NOT UNDERSTAND WHAT AN ELECTRONIC SIGNATURE IS (if you choose this answer, do not continue. Please call 1-714-679-9949 for explanation)

Client Name*

Which service you want?*

Describe "Other" Procedure Here:

I hereby authorize Michelle Lynn to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.*

I hereby authorize Michelle Lynn to take photographs of the work performed both before and after treatment to be maintained only in file.*

I have informed Michelle Lynn that I am in good health and not under the care of any physician.*

Physician’s Address*

I Acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about permanent makeup from Michelle Lynn and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the matters set forth and agree as follows:*

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure.*

I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results.*

I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment;*

I understand that if I have Oily Skin that my strokes may not heal as crisp secondary to the overactive sebaceous glands in my skin.*

I acknowledge that obtaining permanent makeup is my choice alone. The application of permanent makeup will result in a permanent change to my appearance, and that needles and pigments will penetrate the surface of my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent makeup to the original condition, and it is very costly to remove.*

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my blood.*

If I suffer from hepatitis, or other risk factors for blood borne pathogen exposure, or any other communicable disease, I have informed Michelle Lynn of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my permanent makeup procedure.*

I do not have a history of medications use or currently using medications, including being prescribed antibiotics prior to dental or surgical procedures.*

I have advised the artist of any allergies to latex gloves, soap, or medications. I acknowledge it is not reasonable for the Michelle Lynn to determine whether I might have an allergic reaction to the permanent makeup procedure and further acknowledge that such reaction is possible.*

I have truthfully represented to Michelle Lynn that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do not have any physical, mental impairment or disability that might affect my well-being as a direct or in direct result of my decision to have permanent makeup at this time.*

I acknowledge infection is always possible as a result of permanent makeup application, and I agree to follow all suggested instructions concerning the care of the permanent makeup site while it is healing.*

I understand I will have permanent makeup applied using appropriate instruments and sterilization techniques. I understand that the permanent makeup site usually takes 6-8 weeks to heal.*

I agree to release and forever discharge, and hold harmless, the artist, all employees, contactors, management and owners of Michelle Lynn from any and all claims of negligence, damages, or legal actions arising from connected in any way with my permanent makeup, the procedure, and conduct used in my permanent makeup procedure and assume all responsibility for the decisions made consenting to this procedure.*

However, spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to (choose one):*

YES, WAIVE a spot test prior to application and I agree to release Michelle Lynn assistants and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments.NO, I do not agree

I understand that inks, dyes, and pigments have not been approved by the Federal Food Administration and that the health consequences of using these products are unknown.*

I have been told that allergic reactions to pigment are very rare, however, they can and do occur and when they occur they can be serious and especially difficult and very troublesome to treat.*

I have been told that this procedure will involve pain and discomfort.*

I understand the markings are permanent and that there is a possibility of hyper pigmentation resulting from a procedure, especially in individuals prone to hyper pigmentation from a scar or other injury.*

I have been told that a follow up procedure may be required.*

I have been told that there is a chance that I may experience a corneal abrasion. When getting eyeliner.*

Other risks involved with the procedure may include, but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction(s) to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.*

I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me.*

I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.*

I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify Michelle Lynn and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and Michelle Lynn or the breach thereof, shall be settled by arbitration in the state of in accordance with the Rules of the American Arbitration Association and judgment of the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.*

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Michelle Lynn a health care practitioner, Department of Health, Drugs and Medical Devices Division.*

I certify this form has been fully explained to me and I have read it or it has been read to me. I understand its contents.*

I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its contents.*

Today's Date*

Age*

Birth date*

Name

Home Address

Email Address

Cell Phone

Occupation

Are you now or have you been under the care of a physician within the last two years?

YESNO

Name*

Phone*

Address*

List all medications you are currently taking, including Retin A, Glycolic Acid and Acutane:*

List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams):*

Have you recently undergone a skin peel?*

YESNO

What products do you use for skin care?*

Abnormal Heart Condition*

YESNO

Corneal Abrasions*

YESNO

Cold Sores*

YESNO

Eye Surgery or Injury*

YESNO

Herpes Simplex*

YESNO

Blepharoplasty (eyelid surgery)*

YESNO

Hemophilia*

YESNO

Visual Disturbances*

YESNO

High or Low Blood Pressure*

YESNO

Cancer*

YESNO

Prolonged Bleeding*

YESNO

Tumors/Growths/Cysts*

YESNO

Circulatory Problems*

YESNO

Chemotherapy/Radiation*

YESNO

Epilepsy*

YESNO

Are you pregnant?*

YESNO

Diabetes*

YESNO

Hepatitis?*

YESNO

Fainting Spells/Dizziness*

YESNO

Do you wear contact lenses?*

YESNO

Cataracts*

YESNO

Do you use tobacco products?*

YESNO

Glaucoma*

YESNO

HIV?*

YESNO

“Dry Eye”*

YESNO

Are you using any eye drops or other ocular medications?*

YESNO

Have you ever experienced hyper-pigmentation from an injury?*

YESNO

Are you currently taking aspirin or ibuprofen?*

YESNO

When was your last eye exam?*

Examining Physician*