COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

TATTOO CONSENT FORM CONSENT TO PERMANENT MAKE-UP AND TATTOO APPLICATION, RELEASE AND WAIVER OF ALL CLAIMS THIS DOCUMENT IS 4 PAGES. PLEASE INITIAL ON THE LINE PROVIDED AFTER READING TO SHOW THAT YOU UNDERSTAND EACH PROVISION. FEEL FREE TO ASK ANY QUESTIONS REGARDING THIS WAIVER. CLIENT'S NAME: TECHNICIAN'S NAME: PROCEDURE(S)TO BE PERFORMFD- AREAS) ON THE BODY TO BE TATTOOED: COST OF PROCEDURE(S): NO. OF VISITS REQUIRED: TOUCH UP: I ACKNOWLEDGE BY SIGNING THIS RELEASE THAT 1 HAVE BEEN GIVEN THE FULL OPPORTUNITY TO ASK ANY AND ALL QUESTIONS WHICH I MIGHT HAVE ABOUT:;STAINING PERMANENT IVIAKE-LI^r OR TATTOO FROM (HEREINAFTER CALLED"TECHNICIAN")AND THAT ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY FULL AND TOTAL SATISFACTION. IN CONSIDERATION OF RECEIVING A TATTOO FROM DREAMSCAPE BROWS LLC INCLUDING ITS OWNERS, PARTNERS,ARTISTS, TECHNICIANS,ASSOCIATES,APPRENTICES,AGENTS,OR ANY EMPLOYEES (HEREINAFTER REFERRED TO AS "DREAMSCAPE BROWS"), I AGREE TO THE FOLLOWING: 1, (PRINT NAME) HAVE BEEN FULLY INFORMED OF THE NATURE, RISKS,AND POSSIBLE COMPLICATIONS AND CONSEQUENCES OF PERMANENT SKIN PIGMENTATION WITH COSMETIC& BODY TATTOOS. I UNDERSTAND THE PERMANENTSKIN PIGMENTATION PROCEDURE CARRIES WITH IT KNOWN AND UNKNOWN COMPLICATIONS AND CONSEQUENCES ASSOCIATED WITH THIS TYPE OF COSMETIC/TATTOO PROCEDURE, INCLUDING BUT NOT LIMITED TO: INFECTION, ALLERGIC REACTION TO PIGMENTS,AFTERCARE PRODUCTS AND/OR SOAP,SCARRING, INCONSISTENT COLOR AND SPREADING, FANNING OR FADING OF PIGMENTS, HAVING BEEN INFORMED OF THE POTENTIAL RISKS ASSOCIATED WITH GETTING A TATTOO 1 WISH TO PROCEED WITH THE TATTOO PROCEDURE AND APPLICATION AND FREELY ACCEPT AND EXPRESSLY ASSUME ANY AND ALL RISKS THAT MAY ARISE FROM TATTOOING. 1 WAIVE AN VI WF!FACT Tn THF 1-1 111 GCT FXTFKIT DFRNAITEf"I RV I A IA/ AKIV DCDCnnI OFD DE A I%fiCrA nC oonAelc L FROM AL IL./11V W�.l1f L UI\V VVJ VI L LIABILITY WHATSOEVER, INCLUDING BUT NOT LIMITED TO, ANY AND ALL CLAIMS OR CAUSES OF ACTION THAT I, MY ESTATE, HEIRS, EXECUTORS OR ASSIGNS MAY HAVE FOR PERSONAL INJURY OR OTHERWISE, INCLUDING ANY DIRECT AND/OR CONSEQUENTIAL DAMAGES,WHICH RESULT OR ARISE FROM THE PROCEDURE AND APPLICATION OF MY TATTOO,WHEATHER CAUSED BY THE NEGLIGENCE OR FAULT OF EITHER THE TATTOO STUDIO, OR OTHERWISE. I HAVE TRUTHFULLY REPRESENTED TO THE TECHNICIAN THAT 1 AM 18YEARS 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,OR MEDICAL IMPAIRMENT OR DISABILITY THAT MIGHT AFFECT MY WELL-BEING AS A DIRECT OR INDIRECT RESULT OF MY DECISION TO HAVE ATATTOO AT THIS TIME. I ACKNOWLEDGE THAT OBTAINING TATTOOS INCLUDING PERMANENT MAKE-UP IS MY CHOICE ALONE.THE APPLICATION OF TATTOOS AND PERMANENT MAKE-UP WILL RESULT IN A PERMANENT CHANGE TO MY APPEARANCE,AND THAT NEEDLES AND INKS WILL GO INTO MY SKIN. I UNDERSTAND THAT AFTER THE PROCEDURE THE ACTUAL COLOR OF THE PIGMENT MAY BE MODIFIED SLIGHTLY, DUE TO THE TONE AND COLOR OF MY SKIN. NO REPRESENTATIONS HAVE BEEN MADE TO ME AS TO THE ABILITY TO LATER RESTORE THE SKIN INVOLVED IN PERMANENT MAKE-UP TO THE ORIGINAL CONDITION,AND IT IS VERY COSTLY TO REMOVE. 1