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Disclosure and Consent for Tattoo and Dermal Procedures This agreement is entered into by and between and ("Client'}.In consideration of the conditions and covenants set forth in this agreement,technician and client agree as follows: I as a client have requested that you describe the procedure to be utilized so I may make an Informed decision whether not to go this procedure. I voluntarily request as my permanent cosmetic technician, technical assistance as she may deem necessary to perform on my body the following procedure(s): 1. Eyeliner or lash enhancement: 2. Eyebrows: 3. Lip liner or full Lip color: 1.Services Provided and Fee: The client desires the following service,which fee and tax shall be due and payable upon execution of this agreement Amount: 2.Representation/Risks(Please initial) _It bas been explained to me that the procedure to be used is referred to as Micro-Pigmentation or Intradermal Implantation.the process of implanting micro-deposits of pigment into the epidermal layer of the skin. Micro-Pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage or tattoo removal. _It has been explained to me that the practice of this procedure is not an exact science.Colors may not match perfectly or appear exactly as expected. Over thee months and years following the procedure,softening,fading or change of color of the pigment may occur. I understand touch-ups are available at additional cost. I understand that there is a possibility of hyper-pigmentation resulting from a procedure,especially individuals prone to hyper-pigmentation from a scar or other injury. I realize the procedure will probably result in permanent and irreversible color change in dle skin area treated. However rare,some of the possible complications resulting from this is procedure may include infection,scarring,swelling,bruising,numbness,and post procedure discomfort,allergic reaction to one of the pigments or anaesthetic agents(topical or oral).Should an allergic reaction to one of the pigments occur,it may be removed surgically or by laser. 1-understand that the description of the procedure is not meant to scare me 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. 3.Release of Liability I hereby authorize to take full-face photographs of the work performed both before and after treatment,and I further'authorize the use of said photographs to be used for marketing purposes. I have informed: that I am in good health and not under the care of any physician. have informed physician. That I am currently under the care of a Physician Name and Address/Phone: List of Conditions: I understand that no warranty or guarantees have been made to me as to the results of this procedure. I have been told that there may be risks and hazards related to me performance of the procedure planned for me. I have been told that this procedure will most likely involve some pain and discomfort.