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❑Rosacea <br /> ❑Hyperpigmentation <br /> ❑Keloid <br /> ❑Concave Scarring <br /> ❑None of these <br /> Is there any other information you feel you should provide to your technician; any other <br /> issues you wish to discuss or address prior to your procedure? <br /> ❑Yes []No <br /> Please disclose: <br /> RISKS AND HAZARDS ACKNOWLEDGEMENT <br /> Please initial each section to indicate that you have read and understand the following <br /> statements, and that you agree with these statements. <br /> I understand makeup is a form of permanent tattoo that requires the <br /> implantation of pigment through my skin using a needle. <br /> I understand the risks and hazards related to the performance of this <br /> procedure which may include, but are not limited to infection, allergic reaction to <br /> pigment and/or other products used, dizziness, bleeding, bruising, swelling, scarring, <br /> difficulties in detecting melanoma, fading and fanning/spreading and/or pigment <br /> migration. <br /> I understand that it is my responsibility to advise my technician of any <br /> questions or concerns I have before the start of my procedure, even if I have not <br /> included them here in this form. <br /> I understand there is a no refund policy, and no warranty or guarantee has <br /> been made to me because of this procedure. <br /> Although my technician will do their best to ensure I am happy with the result, <br /> the final result cannot be guaranteed. <br />