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Disclosure and Consent for Tattoo and Dermal Procedures <br /> (page 2 of 2) <br /> Initial Please(no�Is) <br /> I understand that no warranty or guarantees have been made to me as a result of my procedure. <br /> I understand that there is a possibility of hyper-pigmentation resulting from the procedure, especially in <br /> individuals prone to hyper-pigmentation from scar or other injury. <br /> I have been told that there may be risk and hazards related to the procedure planned for me. <br /> I have been told that this procedure will involve pain and discomfort. <br /> I understand that the pigments being used are not FDA approved and health consequences are unknown. <br /> I have been told that the markings are permanent and there is a risk of pigment migration and infection <br /> following the procedure. <br /> I have been told that a follow-up procedure may be required and that the color or the pigmentation may fade. <br /> I have been told that there is a chance that I may experience a corneal abrasion from the eyeliner procedure. <br /> I have been told that there is a chance of allergic reaction to pigment and that my body may reject the <br /> pigment. <br /> I have been given the opportunity to ask questions about the procedure and the procedure to be used, the <br /> risks and the hazards involved, and I believe that I have sufficient information to give this informed <br /> consent. <br /> I have agreed that if I shall have a complaint of any kind, whatsoever, I shall immediately notify Lisa Marie <br /> Bates. I further agree that any controversy or claim arising out of or relating to this consent and or <br /> any signed contract between myself and Lisa Marie Bates or the breach thereof, shall be settled by <br /> arbitration in the state of California in accordance with the Rules of the American Arbitration <br /> Association and judgment of the award rendered by the arbitrator(s) may be entered in any court <br /> having judgment thereof. <br /> I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify <br /> Lisa Marie Bates. <br /> I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read <br /> it or it has been read to me. I understand its content. <br /> I certify that this form has been explained to me and I have read it. I understand its content. <br /> Print Name Date <br /> Signature <br />