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i • d-C� a Disclosure and Consent for Cosmetic Tattoo anDermal Procedures (page 1 of 2) I, as a client, have requested that Jenna describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. Jenna has described the recommended procedure to be used as Micro Pigment implantation, the process of implanting micro insertions into the dermal layer of the skin. Micro Pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic make-up and skin imperfection camouflage. Please Initial I hereby authorize Jenna to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising. OR I hereby authorize Jenna to take photographs of the work performed both before and after treatment to be maintained in my file. I have informed Jenna that I am in good health and not under the care of any physician. OR I am currently under the care of a Physician. Physician's Name&Specialty Address, City, State, Zip Phone# I am being treated for the following condition(s): I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give my consent for this procedure. I understand that no warranty or guarantees have been made to me as a result of my procedure. I understand that there is a possibility of hyper-pigmentation resulting from the procedure, especially in individuals prone to hyper-pigmentation from scar or other injury. I understand that the inks used in this procedure are not FDA approved and health consequences are unknown. }