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ThINK
<br /> 8 E A U T V
<br /> ThINK Beauty. LLC I Scalp Micropigmentation (SMP) 11110 W Kettleman In. Lodi CA I Phone No. (209) 310-4066
<br /> Client Information
<br /> Print Name: D.O.B: Age: Date:
<br /> Address: City: State: Zip:
<br /> Phone #: Driver's License/I.D. #: E-mail:
<br /> Emergency Contact: Relationship: Phone #:
<br /> Print Name
<br /> Medical History
<br /> MEDICAL HISTORY QUESTIONNAIRE' YES NO If"YES" to any question, please explain
<br /> 1. Have you ever received SMP before?
<br /> 2. Are you pregnant?
<br /> 3. Do you have a heart condition, epilepsy or diabetes?
<br /> 4. Are you a hemophiliac (bleeder) or on any medication(s) that may
<br /> cause bleeding or may hinder blood clotting?
<br /> 5. Do you have any communicable diseases? PLEASE BE HONEST
<br /> (i.e. HIV, AIDS, HEPATITIS, etc.)
<br /> 6. Are you under the influence of alcohol or drugs, prescribed or
<br /> otherwise? PLEASE BE HONEST
<br /> 7. Do you have any allergies? (i.e. Medicines or topical solutions)
<br /> 8. Do you smoke or use steroids
<br /> Client Consent, Waiver and Release of Liability
<br /> Int. 1. To my knowledge, 1 do not have any physical, mental or medical impairment or disability which might affect my well-being which might affect
<br /> as a direct or indirect result of my decision to receive SMP at this time.
<br /> Int. 2. I agree to follow all instructions concerning the care of my SMP while it's healing. I agree that any touch up work, due to my negligence, will be
<br /> done at my own expense.
<br /> Int. 3. Being of sound mind and body, I hereby release ThINK Beauty LLC any and all its affiliates, employees, directors, officers, trainers, students,
<br /> agents and/or persons representing ThINK Beauty LLC from any and all responsibility, liability, loss, damage, cost and other expense in
<br /> connection to and/or arising out of SMP procedure. 1 agree not to sue ThINK Beauty LLC, its affiliates, directors, officers, agents, heirs,
<br /> employees, trainers, students and/or persons representing ThINK Beauty LLC or assigns in connection with any and all damages, claims,
<br /> demands, rights and causes of action of whatever kind or nature based upon injuries or property damages to or death of myself or any other
<br /> persons arising from my decisions to have SMP work at this time, whether arising directly or indirectly caused by ThINK Beauty LLC's, its
<br /> affiliates', employees', directors',officers', trainers', students', agents' and/or persons' representing ThINK Beauty LLC negligence, recklessness
<br /> or willful misconduct.
<br /> Int. 4. 1 acknowledge and understand that ThINK Beauty. LLC, its affiliates, employees, trainers, students, representatives and employees ("ThINK
<br /> Beauty LLC, et. al.") make no attempt to, or claim to, being a healthcare professional practicing medicine and because each individual body is
<br /> unique it is not reasonably possible for ThINK Beauty LLC, et. al. to attempt to, or claim to, or determine whether I might have an allergic
<br /> reaction to the pigments, materials or processes used in my SMP procedure, and I agree to accept the risk that such a reaction is possible and I
<br /> agree to seek medical attention from a healthcare professional should an allergic reaction and/or any health causing effect from SMP procedure.
<br /> Int. 5. I agree for myself, my heirs, assigns and legal representatives to hold harmless from any and all liabilities, damages, loss, actions, causes of
<br /> action, claim judgments, costs of litigation, attorney's fees and all other costs and expenses which might arise or in connection from my decision
<br /> to have SMP done by ThINK Beauty LLC, et. al.
<br /> Int. 6. 1 have been advised that SMP will be permanent and that it can only be removed with a laser procedure, and that any effective removal may
<br /> possibly leave permanent scarring and disfigurement. This cautionary notice is required to be provided to me by the health department and I
<br /> hereby acknowledge receipt of this formal notice.
<br /> Int. 7. I agree to grant ThINK Beauty LLC permission to photograph, record,videotape and/or audiotape me undergoing the entire phase of my
<br /> SMP procedure (collectively as the "Recordings"). I further agree to waive any and all right to the Recordings, and further assign my
<br /> rights of Recordings over to ThINK Beauty. LLC for its own use how it see fit, including and not limited to marketing and educational
<br /> purposes. By initialing this section, I grant this consent, and further understand and agree that no monetary or other consideration is
<br /> owed to me by ThINK Beauty LLC or any other party in respect of the grant of this consent or use and distribution of the Recordings.
<br /> Int. 8. I swear or affirm and agree that the above information is true and correct.
<br /> I have been provided with information describing the SMP procedure to be performed and instructions on after care. I have been made aware that if I
<br /> have any signs or symptoms of infection, such as swelling, pain, redness, warmth, fever, unusual discharge or odor to contact my physician. It is also
<br /> my responsibility to take care of the treated site according to the instructions provided both verbally and in writing.
<br /> Customer Signature: Date:
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