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been advised of the matters set forth below and agree as follows: Initials at each line: I acknowledge that obtaining permanent make-up is my choice alone. The application of permanent make-up will result in a permanent change to my appearance, and that needles and inks will go into 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. I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thin the blood. If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my tattoo. I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the permanent make-up, or any open wounds or lesions at the site of the tattoo. I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures. I have advised the Technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reaction to the permanent make-up process and further acknowledge that such reaction is possible. I have truthfully represented to the Technician 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, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have a tattoo at this time. I acknowledge infection is always possible as a result of permanent make-up application, and I agree to follow all suggested instructions concerning the care of the permanent make-up site while it is healing. I acknowledge that inks are not FDA approved and health consequences are unknown.