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RECEIVE WAIVEA spot test prior to application and I agree to release Cynthia Vasquez , assistants and pigment manufacturer( s) from any and all liability related to allergic reaction or any other reaction to applied pigments . I have been told that allergic reactions to pigment are very rare , however, they can and do occur and when they occur, they can be serious and especially difficult to treat . I understand the markings are permanent and that there is a possibility of hyperpigmentation resulting from a procedure , especially in individuals prone to hyperpigmentation from a scar or other injury. I have been told that a follow up procedure may be required . I understand that any further touch ups needed will not be covered and additional cost may occur. I have been told there is a chance that I may experience a corneal abrasion . Other risks involved with the procedure may include but not limited to : infections , allergic and other reaction (s) to applied pigments , allergic and other reaction ( s) to products applied during and after the procedure , fanning or spreading of pigment ( pigment migration ) , fading of color and other unknown risks . I accept full responsibility for any and all , present and future , medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me . I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent . I have agreed that should I have a complaint of any kind whatsoever, I shall immediately inform Cynthia Vasquez and I further agree that any controversy of claim arising out of or relating to this consent and /or any signed contract between myself and Practitioner or the breach thereof, shall be settled by arbitration in the state of California in accordance with the Rules of the American Arbitration Association and judgment of the award rendered by the artitrator (s) may be entered in any court having jurisdiction thereof. I understand that if I have an infection , adverse reaction or allergic reaction to the procedure , I must notify Cynthia Vasquez and my health care practitioner. I certify this form has been fully explained to me and I have read it or it has been read to me . I understand its contents . I have received a copy of the Post Procedure Instructions . It has been fully explained to me and I have read it or it has been read to me . I understand its contents . Signature Date Medical History Form Today ' s Date : _/ / Birth Date : _/_/ Name : 0. a 3 G