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I agree to (circle one): RECEIVE WAIVE a spot test prior to application and I agree to release technician and salon, assistants and pigment manufacturer(s), distributor(s) from any and all liability related to allergic reaction or any other 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 hyperpigmentation from a procedure, especially in individuals prone to hyperpigmentation from a scar or other injury. I have been told that a follow up procedure may be required. 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 understand there are risks for blood borne pathogen related illnesses such as Human immunodeficiency virus (HIV), Hepatitis B virus (HBV), and Hepatitis C virus (HCV) the 3 most common blood borne pathogens. 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 the opportunity to ask questions about the procedures and the procedure used 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 technician 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 technician/salon or the breach thereof, shall be settled by arbitration in 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 technician right away. 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. Signature Date