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22 Please seek legal advice before using this document! Consent and release agreement for permanent cosmetic procedure Name of Releasor(client): Who resides at(street address) (city) (zip)—(phone)(—) (alt.phone)(— ) Please list your Emergency Contact Below: Name: ® who resides at(street address) ® (city) (zip)—(phone)( )_-_(alt.phone)( AGREEMENT 1. DESCRIPTION OF THE PROCED A. This procedure will implant permanent color to the eyebrows,eyeliner,lips,or other desired area using pre-sterilized, i00% disposable Soffap@ Hand Tools.These tools are made of plastic with surgical stainless steel needles on the end.They are used to gently tap permanent cosmetic pigment into the skin. 2. MMUT TO EXPECT FROM THIS PROCEDURE A. There may be minor swelling and or irritation following this procedure.With proper care,healing should take place within 5-10 days,depending on the individual.See below for risks,the possibility of medical complications,and post treatment instructions. 3. ACKNTOWLEDGE MENT OF THE RISKS OR COMPLICAT IONS ASSOCLATED WTH THE PERAL4NEIVTCQS ET IC TA7TOO PROCEDURE. A. The Releasor has been informed by the Releasee of the possible dangers that may occur as a result of having a permanent cosmetic tattoo procedure performed.The Releasor acknowledges that those dangers may include eye injury from the permanent cosmetic eyeliner procedure,allergies from pigment used in the procedure(s),fever blisters or cold sores from the permanent lip procedure, swelling,bruising(although rare),temporary minor bleeding,redness or pinkness,and soreness.The Releasor understands and acknowledges that the permanent cosmetic tattoo procedure may permanently alter the appearance of the Releasor's face,which may or may not be desirable to the Releasor. B. Now,the Releasor having been fully and completely advised of all inherent risks,dangers,and complications which may arise from a permanent cosmetic tattoo procedure,voluntarily assumes all and any risks,dangers,or complications which may arise as a result of a permanent cosmetic tattoo procedure.To help minimize any risks,the Releasor will answer Yes or No the following conditions in order to describe if the Releasor has any of the following medical conditions: This document is Copyright protected by Sofrap(V Inc. It may not be reproduced without the expressed written permission of SotTap(M Inc. Call 925 248-6301 or write to 550 N.Canyons Parkway,Livermore,CA 94551. All rights reserved. 0 Copyright,2014 SofTap9 Inc. Seek legal advice before using this document.