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�► 0 <br /> CONSENT FOR EYEBROW MICROBLADING PROCEDURE <br /> NAME DATE DOB <br /> ADDRESS CITY <br /> STATE ZIP HO PH WORK PH <br /> I, am over the age of 1 ,am not under the influence of drugs or alcohol and desire <br /> to have microblading of eyebrows performed. The general nature of cosmetic tattooing as well as the specific <br /> procedure to be performed and what to expect after the procedure has been explained to me. X <br /> NO.OF VISITS REQUIRED: COST OF PROCEDURE(s): <br /> I have been informed of the nature,risks,and possible complications and consequences of permanent skin <br /> pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown <br /> complications and consequences associated with this type of cosmetic procedure, including but not limited to: <br /> infection,allergic reaction,scarring, inconsistent color,and spreading, fanning or fading of pigments. I have <br /> been informed that tattoo inks,dyes,and pigments have not been approved by the federal Food and Drug <br /> Administration and that the health consequences of using these products are unknown. X <br /> I understand that after the procedure the actual color of the pigment may be modified slightly,due to the tone <br /> and color of my skin. I fully understand this is a tattoo process and therefore not an exact science,but an art.I <br /> request the microblading procedure and accept the permanence of the procedure as well as the possible <br /> complications and consequences of the said procedure.I understand that while this is sometimes referred to as <br /> semi-permanent in nature,due to each indivudal's reaction to pigment,the length of time pigment is present <br /> cannot be guaranteed. In some cases,pigment will be permanent. X <br /> I understand that if I have any skin treatments,laser hair removal,plastic surgery or other skin altering <br /> procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential <br /> adverse changes may not be correctable. If I am on any medication for depression or any other mood altering <br /> prescription,I will advise my technician. X <br /> I have received pre-and post procedure instructions and I understand them and will strictly adhere to such <br /> instructions.I understand that my failure to do so may jeopardize my chances for a successful procedure.I agree <br /> that it is my responsibility to contact my Technician if there are signs and symptoms of infection, including,but <br /> not limited to redness, swelling,tenderness of the procedure site,red streaks going from the procedure site <br /> towards the heart,elevated body temperature,or purulent inage from the procedure site. X <br /> I understand that the taking of before and after photographs of the said procedure are a condition of such <br /> procedure. I release all rights to any photographs taken of me and the permanent makeup and give consent in <br /> advance to their reproduction in print or electronic form. <br /> I agree to reimburse each of the technician and the Body Art Facility for any attorneys fees and costs incurred in <br /> any legal action I bring against either the Technician or the Body Art Facility and in which either the Technician <br /> or the Body Art Facility is the prevailing party.I agree at the courts of California State,in San Joaquin <br /> County,shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose <br /> of litigating any dispute arising out of or related to this agreement. X <br />