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4100 – Safe Body Art
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PR0541621
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COMPLIANCE INFO
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Entry Properties
Last modified
3/21/2024 2:38:16 PM
Creation date
4/12/2023 3:50:04 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0541621
PE
4120
FACILITY_ID
FA0023856
FACILITY_NAME
VERSAILLES SALON (GREEN-FRESE, ERICA)
STREET_NUMBER
1010
STREET_NAME
CENTRAL
STREET_TYPE
AVE
City
TRACY
Zip
95376
CURRENT_STATUS
01
SITE_LOCATION
1010 CENTRAL AVE
P_LOCATION
03
QC Status
Approved
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SJGOV\cfield
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EHD - Public
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Versailles Salon And Spa <br /> 1010 Central Ave* Tracy,CA 95376 ® Salon(209)836-1505 Cell(209)275-9133 <br /> Disclosure and Consent for Tattoo and Dermal Procedures(continued)... <br /> However, spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I <br /> agree to(circle one): <br /> RECEIVE WAIVE a spot test prior to application and I agree to release Versailles Salon And Spa <br /> assistants and pigment manufacturer(s)from any and all liability related to allergic reaction or any other <br /> reaction to applied pigments. <br /> I have been told that allergic reactions to pigment are very rare,however,they can and do occur and <br /> when they occur they can be serious and especially difficult and very troublesome to treat. <br /> I have been told that this procedure will involve pain and discomfort. <br /> I understand the markings are permanent and that there is a possibility of hyper pigmentation <br /> resulting from a procedure,especially in individuals prone to hyper pigmentation from a scar or other injury. <br /> I have been told that a follow up procedure will be required. <br /> I am 18 years of age <br /> I understand there are other potential risk factors for blood born pathognes. <br /> Other risks involved with the procedure may include,but not limited to:infections,allergic and other <br /> reaction(s)to applied pigments,allergic and other reaction(s) to products applied during and after the <br /> procedure,fanning or spreading of pigment(pigment migration),fading of color and other unknown risks. <br /> I accept full responsibility for any and all,present and future,medical treatment(s) and expenses I may <br /> incur in the event I need to seek treatment(s)for any known or unknown reason associated with the procedure <br /> planned for me. <br /> I have been given an opportunity to ask questions about the procedures and the procedure to be used <br /> and the risks and hazards involved and I believe that I have sufficient information to give this informed <br /> consent. <br /> I have agreed that should I have a complaint of any kind whatsoever,I shall immediately notify <br /> Versailles Salon And Spa <br /> and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed <br /> contract between myself and Versailles Salon And Spa <br /> or the breach thereof,shall be settled by arbitration in the state of California in accordance with the Rules of <br /> the American Arbitration Association and judgment of the award rendered by the arbitrator(s)may be entered <br /> in any court having jurisdiction thereof. <br /> I understand that if I have an infection,adverse reaction or allergic reaction to the procedure,I must <br /> notify Versailles Salon And Spa <br /> a health care practitioner,California Department of Health,Drugs and Medical Devices Division. <br /> I certify this form has been fully explained to me and I have read it or it has been read to me. I <br /> understand its contents. <br /> I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have <br /> read it or it has been read to me.I understand its contents. <br /> Signature Date <br /> Medical History Form <br /> Today's Date: / / Birth date: <br /> C:\Users\Versailles 2\Downloads\2017 REVISED Consent Form TEMPLATE.docx Rev:12/5/2016 Page 4 of 8 <br />
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