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Lisa Marie Sates <br /> Permanent Cosmetic Technician <br /> 209-640-7895 <br /> Disclosure and Consent for Tattoo and Dermal Procedures <br /> (page 1of2) <br /> I, as a client, have requested that Lisa Marie Bates <br /> describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the <br /> procedure. <br /> Lisa Marie Bates has described the recommended procedure to be used as Micro Pigment implantation, <br /> the process of implanting micro insertions into the dermal layer of the skin. Micro Pigment Implantation is a form of <br /> tattooing used for the purpose of permanent cosmetic make-up and skin imperfection camouflage. <br /> I voluntarily request as my Permanent Cosmetic Technician, Lisa Marie Bates and technical assistance as <br /> she may deem necessary to perform on my face and/or body the following procedure(s): <br /> Initial Please(no�'s) <br /> I hereby authorize Lisa Marie Bates to take photographs of the work performed both before and after <br /> treatment, and I further authorize the use of said photographs to be used for the purpose of advertising. <br /> OR <br /> I hereby authorize Lisa Marie Bates to take photographs of the work performed both before and after <br /> treatment to be maintained in my file. <br /> I have informed Lisa Marie Bates that I am in good health and not under the care of any physician. <br /> OR <br /> I am currently under the care of a Physician. <br /> Physician's Name&Specialty <br /> Address, City, State, Zip <br /> Phone# <br /> I am being treated for the following condition(s): <br /> I am 18 years or older. <br /> I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to <br /> make me better informed so that I may give my consent for this procedure. <br />