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Disclosure and Consent for Tattoo and Dermal Procedures
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Disclosure and Consent for Tattoo and Dermal Procedures
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 signatures
I 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
*
First
Last
I, as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. You have described the recommended procedure to be used as Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin. Micro pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage. I voluntarily request as my intradermal cosmetic artist, Michelle Lynn and such association and technical assistance as she may deem necessary to perform on my body the following procedure.
*
UPPER EYELID
LOWER EYELID
LOWER MUCOSAL EYELID
POWDER EYEBROW
FULL LIP COLOR
LIPLINER
FULL LIPS CORRECTION PROCEDURE
AREOLAS
MICROSTROKE BROWS
OTHER (describe below)
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.
Please Initial:
I hereby authorize Michelle Lynn to take photographs of the work performed both before and after treatment to be maintained only in file.
Please Initial:
I have informed Michelle Lynn that I am in good health and not under the care of any physician.
Please Initial:
I am currently under the care of a physician and I am being treated for the following condition(s):
Describe:
Physician’s Name
Physician’s Phone
Physician’s Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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:
Please Initial:
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.
Please Initial:
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.
Please Initial:
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;
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
I do not have a history of medications use or currently using medications, including being prescribed antibiotics prior to dental or surgical procedures.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
However, spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to (choose one):
*
RECEIVE 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.
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.
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.
Please Initial:
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.
Please Initial:
I have been told that this procedure will involve pain and discomfort.
Please Initial:
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.
Please Initial:
I have been told that a follow up procedure may be required.
Please Initial:
I have been told that there is a chance that I may experience a corneal abrasion. When getting eyeliner.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
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.
Please Initial:
Medical History Form
Today's Date
Date Format: MM slash DD slash YYYY
Age
Birth date
Date Format: MM slash DD slash YYYY
Name
First
Last
Home Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email Address
Home Phone
Cell Phone
Employer
Occupation
Are you now or have you been under the care of a physician within the last two years?
*
Yes
No
If yes, please provide Physician’s Name, address and phone number
Person to contact in an emergency:
Name
First
Last
Phone
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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?
What products do you use for skin care?
Do you have or have you had any of the following conditions (answer Yes or No):
Abnormal Heart Condition
Yes
No
Corneal Abrasions
Yes
No
Cold Sores
Yes
No
Eye Surgery or Injury
Yes
No
Herpes Simplex
Yes
No
Blepharoplasty (eyelid surgery)
Yes
No
Hemophilia
Yes
No
Visual Disturbances
Yes
No
High or Low Blood Pressure
Yes
No
Cancer
Yes
No
Prolonged Bleeding
Yes
No
Tumors/Growths/Cysts
Yes
No
Circulatory Problems
Yes
No
Chemotherapy/Radiation
Yes
No
Epilepsy
Yes
No
Are you pregnant?
Yes
No
Diabetes
Yes
No
Hepatitis?
Yes
No
Fainting Spells/Dizziness
Yes
No
Do you wear contact lenses?
Yes
No
Cataracts
Yes
No
Do you use tobacco products?
Yes
No
Glaucoma
Yes
No
HIV?
Yes
No
“Dry Eye”
Yes
No
Are you using any eye drops or other ocular medications?
Yes
No
Have you ever experienced hyper-pigmentation from an injury?
Yes
No
Are you currently taking aspirin or ibuprofen?
Yes
No
When was your last eye exam?
Date Format: MM slash DD slash YYYY
Examining Physician
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