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, Owner of Cosmetic Ink Artistry, 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*

Phone*

Email*

I have been personally advised by the handler about the type, kind and purpose of the treatment, including information about possible anesthetization. I was thoroughly informed about the required behavior, as well as the necessary sun protection before and after the treatment and pointed out possible complications before and after the treatment. In doing so, my personal situation was sufficiently discussed, as well as realistic treatment results. I have received, read and understood the leaflet with general information for the patient on treatment and after treatment. I was also able to ask all the questions I was interested in. These were answered and understood by me, i.e; Specific personal risk factors of the patient (medication, operations, sensitivity to light, especially disorders):*

YESNO

Purpose of Treatment:*

Age-warts (seborrheic keratoses)Fibromas (predunculated wart)Skin-colored nevi (dermal nevi)Age spots (lentigines) and light damaged skin (actinic precanceroses)Fat deposits under the skin of eyelids (Xanthelasms)Scars, Acne Scars, Stretch MarksWrinkle smoothing, Eyelid lifting, Skin TighteningOther

Areas of Treatment:*

RISKS: Even if the therapy is carried out in the correct manner, there are certain risks such as: Intolerance of the local anesthetic (cream form), wound infection, wound healing disorders, scarring (extremly rare), pigment disorder (hyper hypopigmentation). Do you understand these risks?*

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 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 Fibroblast Treatment at this time.*

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

I agree to release and forever discharge, and hold harmless, the artist, all employees, contractors, management and owners of Cosmetic Ink Artistry, from any and all claims of negligence, damages, or legal actions arising from, connected in any way, with my Fibroblast Treatment. I 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):*

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 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 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 Daniel or a representative of Cosmetic Ink Artistry, and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself, Michelle Daniel, Cosmetic Ink Artistry, 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 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.*

A sunscreen with a high filter SPF 50 should be used for at least 2-4 weeks*

I am aware that a guarantee cannot be given for the results of the treatment. I have also been informed about the necessity of additional treatments (fee required), which may be necessary to achieve the desired results. Nevertheless, I agree to carry through with the above described treatment. I have been given sufficient time and opportunity to overthink my decision. I do not have any further questions and all concerns I had, have been answered completely and thoroughly. I have received and read the patient information pamphlet and I will follow the instructions. I agree to the Cosmetic Ink Artistry Fibroblast Treatment and waive a 24-hour consideration period.*

YES, I agreeNO, I do not agree

Name*

Date*