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Flawless Ink By nicholette Vonmarkle 227 N Main St Manteca,Ca 95336 (209)407-7274 Consent to permanent makeup release and waiver of all claims I acknowledge by signing this release that I have been giving the full opportunity to ask any and all questions which 1 might have about obtaining permanently make-up from (here after calling "technician")that and that all my questions have been answered to my full and total satisfaction. Procedures to be performed: I specifically acknowledged that I have been advised of the matters set forth below an agree as follows: Initial at each line* I acknowledge that obtaining permanent make-up is my choice alone and 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 representatives have been made to me as to the ability to later restore the skin involved in permanent make-up to the original condition. I am not pregnant or nursing I do not have any history of herpes infections at the purpose procedure site I do not have epilepsy, diabetes,allergic reaction to latex or antibiotics,hemophilia or other bleeding disorders.I do not have cardiac valve disease or suffer from any heart conditions or take medication that thins my 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 that have been advised of any medical and procedures necessary to promote the satisfactory healing of my pigment make-up. I do not suffer from any medical or skin condition(s)such as,but no limited to:keloid or hypertrophic scarring,psoriasis at the side of permanent make-up,or any open wound or lesions at the site of the procedure area. I do not have a history of medication use or currently using medication,including being prescribed antibiotics prior to dental or surgical procedures. [have advised the Technician I have any allergies to latex gloves,so for medications.I acknowledge it is not reasonably possibe for the Technician to determine whether I might have allergic reaction to the permanent cosmetic procedure and further acknowledge that such reactions is possible. I have truthfully represented to the technician that I am 18 years old 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 may affect my wellbeing as a direct or indirect result of my decision to have a permanent cosmetic procedure at this time. I acknowledge infections is always possible as a result of permanent make-up application,and I agreed to follow all suggested instructions concerning the care of permanent make-up while it is healing. I acknowledge and give consent to this permanent makeup studio to use images of my permanent make-up(s)for marketing and,or publish lean purposes in various media such as Internet,magazine,social media,printed or television etc. I understand I will have permanent makeup applied using appropriate instruments and sterilization techniques.I understand that the permanent make-up site usually takes z weeks or longer to heal.I agree to release and forever discharge,and hold harmless,the Technician all employees,contractors,and the management of the permanent make-up studio from any and all claims of negligence,damages,or legal action arising from the connected in any way with permanent make-up cosmetic,the procedure,and conduct using in my permanent cosmetics and assume all responsibility for the decision(s)made consenting to this permanent procedure. I am aware about the permanent cosmetic inks,dyes,and pigments have not been approved by the federal Food and Drug administrations and that the health consequences of using these products are unknown. NAME: PHONE: AGE: DOB: ADDESS: CITY: STATE: ZIP: SIGNATURE: Technician information only. EQUIPMENT USED: PIGMENT USED: LOT OR MODEL NUMBERS: EXPIRATION: