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0 is Versailles Salon And Spa 1010 Central Ave* Tracy,CA 95376® Salon(209)836-1505 Cell(209)275-9133 Disclosure and Consent for Tattoo and Dermal Procedures I, as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. You have described the recommended procedure for microblading to be used at Versailles Salon And Spa the process of implanting micro insertions of pigment into the dermal layer of skin to permanently change the appearance of eyebrows. Microblading is a form of tattooing and the markings are permanent. I understand that there are no tattoo or permanent makeup pigments that have approved by the federal Food and Drug Administration.The health consequences of using these products are unknown. I voluntarily request as my intradermal cosmetic technician,Versailles Salon And Spa and such association and technical assistance as she may deem necessary to perform on my body the following procedure:EYEBROW Please Initial: I hereby authorize Versailles Salon And Spa 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. I hereby authorize Versailles Salon And Spa to take photographs of the work performed both before and after treatment to be maintained only in file. I have informed Versailles Salon And Spa that I am in good health and not under the care of any physician. I am currently under the care of a physician and I am being treated for the following condition(s): Physician's Name: Phone Number: Address: City/State: Zip: Please Initial: 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 or withhold my consent for this procedure. I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results. I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment; C:\Users\Versailles 2\Downloads\2017 REVISED Consent Form TEMPLATE.docx Rev:12/5/2016 Page 3 of 8