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ThINK
<br /> BEAUTY
<br /> ThINK Beauty. LLC I Scalp Micropigmentation (SMP) I 1110 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 heart condition, epilepsy or diabetes? History of
<br /> cardiac valve disease?
<br /> 4. Are you a hemophiliac (bleeder) or on any medication(s) that may
<br /> cause bleeding or may hinder blood clotting? Do you have any
<br /> other bleeding disorders?
<br /> 5. Do you have any communicable diseases? PLEASE BE HONEST
<br /> (i.e. HIV, AIDS, HEPATITIS, Herpes infection on procedure site, etc.)
<br /> 6. Do you have any other risk factors regarding bloodborne
<br /> atho ens?
<br /> 7. Are you under the influence of alcohol or drugs, prescribed or
<br /> otherwise? PLEASE BE HONEST
<br /> 8. Do you have any allergies? Allergic reactions to latex? (i.e.
<br /> Medicines or topical solutions) Allergic reactions to antibiotics?
<br /> 9. Do you smoke or use steroids?
<br /> 10. Are you over the age of 18?
<br /> 11. Are you taking any medications, if so list them.
<br /> 12. Do you require antibiotics before surgeries or dental procedures?
<br /> Client Consent, Waiver and Release of Liability
<br /> Int. 1. To my knowledge, I 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. I 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. I 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. I 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
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