714-679-9949
CosmeticInkArtistry@gmail.com
Product
has been added to your cart.
Home
About Your Artist
Blog
Gift Card
Buy Gift Card
Gift Card Balance
Shop
Training Courses
Services
Microblading
Powder Brow
Combo Brow
Henna Brow Tint
Color Correction
Lip Blush Tattoo
EyeLiner
Areola Restoration Tattooing
Collagen Therapy (skin needling)
Scar Relaxation
Fibroblast Skin Tightening
Body Piercing
FAQ’s
Aftercare Instructions
Pricing Menu
Gallery
Areola Gallery
Brow Gallery
Eyeliner Gallery
Lip Blush Gallery
Consent Forms
Disclosure and Consent for Tattoo and Dermal Procedures
Aftercare Acknowledgement
Areola Aftercare Acknowledgement
Disclosure and Consent Form for Fibroblast Treatment
Contact Us
Message Us
Huntington Beach Location
Bakersfield Location
Privacy Policy
Terms of Service
Disclosure and Consent Form for Fibroblast Treatment
Home
Disclosure and Consent Form for Fibroblast Treatment
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 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
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):
*
YES
No
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 Marks
Wrinkle smoothing, Eyelid lifting, Skin Tightening
Areas of Treatment:
*
Please list the treatment areas in the box above, separated by commas.
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?
*
Please Initial if 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.
*
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 Fibroblast Treatment at this time.
*
Please Initial:
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.
*
Please Initial:
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.
*
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 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 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 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.
*
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:
A sunscreen with a high filter SPF 50 should be used for at least 2-4 weeks
*
Please Initial:
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 agree
NO, I do not agree
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
Menu