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Flawless Ink by Nicki Faber 227 Main St Manteca (209)407-727 COSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE DATE DOBE NAME STATE ZIP ADDRESS qTY--- am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or I, nursing and desire to receive the indicated permanent cosmetic procedure. The general natural of permanent cosmetic as well as the specific procedure to be preformed has been explained to me. PROCEDURE(s) fi OF PROCEDURE VISIT: If OF FOLLOW-UP VISIT: COST OF PROCEDURE(s): I understand that correction procedure are charged on a per visit basis. The number of visit cannot be determined at the time of first treatment. Client has no patiently allow at at least 6.8 weeks healing time to determine if additional procedure(s) are needed (initial) I understand that once the preview of the procedure Is approved by me, there will be no refund giving after the procedure is completed. (initial) the permanent ation. I I have the perhmeen infomed of the natral risk, and anent srkin pigmentation produce carriesiwith knowcomplications and unknown complicationfand consequence assod tedtwith this type of understand cosmetic procedure, including, but not limited to: infection, scarring, Inconsistent color and spreading, fanning or fading of pigments, dified ightly, due to the of m understand and the actual color ss and therefolre not a exament ct seen eay be ob t an art, I request the permanent skinne and pigmentation procedure(s)y skin. I fully ,'and is is uences of the stated accept permanence of the procedure as well as the possible complication and conseq procedure(s). (initial) not ensure clients There is a possibility of an att have a reaction to the pigment. A patch Initial) the paatchowever test, If waved, 1 release the technic an fill rom liability if I initial and wave .(Initial) p allergic reaction. 1 consent (� ) develop an allergic reaction pigment. other skin I understand permanent at if I tav I acknownledge some la er hair se potential removal,adverse changes may not 6e correctable �t may result In adverse change to cos (initial) 1 have received pre and post procedures instructions and I will strictly advise to such instructions. ) understand that d alternative failure toative prescrriptions, I do so may jeopardize my chance of successful procedures(s). If 1 am on any medications for depressions or any other moo will advise my technician. (initial) ify I have read proce in t aledtall above paragraphs and ha eehad to explain to my understandings thus consent pro edures permits accept full responsibility for the decisions to have this cosmetic procedure(s) work done. (' nidal) I understand I will have permanent make-up applied using appropriate instruments and sterilization techniques. I understand that the usually takes 2 weeks or longer to heal. I agree to release and forever discharge and hold harmless the technician, permanent make-up site legalaii ces or tion arising from or connecedin a ay with my permanent make-up, the iprocedu es, and conduct used n my permanent cosmeticgmetic and assume all responsibility for the decision(s) made consenting to this permanent procedures) (initial) DATE: CLIENT SIGNATURE: DATE: TECHNICIAN: