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I understand I will have permanent make-up applied using appropriate instruments and sterilization techniques . I understand that the permanent make-up site usually takes 2 weeks or longer to heal . I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors, and the management of the permanent make-up studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure . I am aware that tattoo inks, dyes , and pigments have not been approved the federal Food and Drug Administration and that the health consequences of using these products are unknown . I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site . I do not have epilepsy, diabetes , allergic reaction to latex or antibiotics , hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my blood . If I suffer from hepatitis , or other risk factors for bloodborne pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my tattoo . I do not suffer from any medical or skin condition(s) such as , but not limited to : keloid or hypertrophic scarring, psoriasis at the site of the permanent make-up , or any open wounds or lesions at the site of the tattoo . I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures . I have advised the Technician of any allergies to latex gloves, soaps , or medications . I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reaction to the permanent make-up process and further acknowledge that such reaction is possible . I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure (s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize (Flawlous Keli Degenstein), as my eyebrow microblading technician to perform on my body the Microblading/3D Eyebrow Embroidery procedure desired today. Print Name Signature Date STATEMENT OF CONSENT