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11. I give my consent to confer with my physicians for medical information required <br />for the safety of my procedures. <br />1Z. I agree to accompany my technician to the emergency room in the event they <br />were to be accidentally stuck with my needle and take a blood test for their safety <br />and disclose all test results to my technician. <br />13. I am aware that if an infection occurs after I have received permanent cosmetics <br />to see my primary physician and to contact my Technician in that regard. <br />14. If I had permanent cosmetics performed previously by another technician, I will <br />not hold Jeff Becker responsible for future allergic reactions or contraindications. <br />15.I understand that the taking of before and after photographs of the said <br />procedure(s) are for the purpose of documentation, which may or may not be <br />used for educational or advertising purposes. <br />16. I am over the age of 18, and not under the influence of any drug or alcohol. <br />17. I have received a copy of my aftercare instructions to follow for 7-10 days. <br />18. I am aware that permanent cosmetic inks, dyes, and pigments have not been <br />approved by the federal Food and Drug Administration and that the health <br />consequences of using these products are unknown. <br />ACCEPTANCE: <br />I have read and understand these risks listed above and they have been explained to <br />me. I DID NOT JUST SIGN THIS DOCUMENT. I certify that the information in the <br />above questionnaire is accurate and that it has been explained to me and my <br />questions have been answered. I accept full responsibility for any complications that <br />may arise or result during or following the cosmetic procedure(s) to be performed at <br />my request. <br />Signature of Client: Date: <br />Signature of Technician: Date: <br />3 <br />