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0 ~_° ~ NATHAN A.KmuD[KID,INC S 8 SURGERY drkludt@pscstockton.com 0p|omato.American Board nfp|amjcSurgery 1oosw'co|nnmia�e�' Suite 405 CENTER STOCKTON Stwcmon'c^eszn4 Phone(2U9)a70-7100 Fax(ZV9)a7e71z6 COSMETIC � � `~[]� �� T� � AND RECONSTRUCTIVE SURGERY www.»scstockton.com 3D Hair Strokes Patient Waiver and Release Agreement |am at least 18 years of age._____(initial) I understand that I will be receiving a semi-permanent cosmetic procedure,3D Hair Strokes,which enhance the eyebrows. (initial) I understand this procedure has had results for some patients that have lasted up to more than 12 months.These results vary and I understand that nntimeframe isguaranteed tome.____(initia|) I understand that this is a cosmetic semi-permanent tattoo and while,with time,pigments can and will fade.Colors also change according tnmetabolism,lifestyle,skin type, medications,age,smoking,alcohol,sun exposure,and use of chemicals such as Retin-A andG|ycuUcacids.Touchupmaintenancewnrkwi||beexpectedinthefuturetokeepit|ookingfresh.____(initia|) I acknowledge that no guarantees have been made to me concerning the results of this procedure and agree that the professional recommendation is"natural look".____(initiu|) I understand that there are some known possible complications of semi-permanent cosmetic procedures including redness,swelling, puffiness,corneal abrasions,dark patches,allergic reactions,tenderness,infection,or migration. In addition, I understand that there is a possibility of hyperpigmentation or scarring resulting from a procedure,especially in individuals prone to hyperpigmentation from ascar orother injury.____(inida|) I understand that it is normal to lose approximately 1/3 of the color during the healing process.I realize that after the procedure the color will appear to be too dark and approximately after 7 days the color will appear to change.After about 10 days the color will appear inits final form and will appear softer.____(initia|) I realize there will be a period of time when scabs may from and the skin may slough/flake off and that I am not to touch the areas during this time. Picking at,pulling or scratching off or otherwise removing sloughing skin may result in loss of color._(initial) I understand the nature of the procedure and possible complications or adverse effects that may occur as a result of applied pigments. Inks are not FDA approved and health consequences are unknown. (initial) I understand that I will receive and will acknowledge pre and post procedure instructions and agree to strictly adhere to such instructions.I understand that achieving the results I desire will,in some measure,be determined by my compliance to post procedure instructions.____(initia|) |accept responsibility for approving the color,shape,and position ofthe pigments that will beapplied and will approve such applications before the procedure begins. I understand that actual color of the pigment may be modified slightly due to the tone and color of my skin.Due to the elasticity of my skin,the shape may change slightly from that which I originally approved.I also understand that pigment unpredictably attaches to some areas of the skin more intensely than other areas and may appear darker or lighter than originally intended. However I know that every effort will be made to make the final result flawless._(initial) I understand that topical anesthetics will be used for my comfort and to enhance the semi-permanent cosmetic procedure and experience. I realize that there are some people who are allergic to topical anesthetics and will make any such allergies or problems known prior to the procedures. I will inform Plastic Surgery Center of Stockton of any condition which may make any of the procedurescnntraindicatedinc|udingnecenthepatitisorpregnanqy,medications,hea|thissues,nrpecsnna|isues.____(initia|)