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J Sharon Cruz *rtified Microfflade Artist ( 612-0430 Disclosure and Consent for Permanent Cosmetics I, am 18 years of age or older and as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. You have described the recommended procedure to be used as Permanent Makeup, the process of implanting micro insertions of pigment into the dermal layer of skin. Permanent Makeup is a form of tattooing and the markings are permanent. I understand that there are no tattoo or permanent makeup pigments that have been approved by the federal Food and Drug Administration.The health consequences of using these products are unknown. I voluntarily request as my intradermal cosmetic technician,Sharon Cruz and such association and technical assistance as she may deem necessary to perform on my body the following procedure (circle one): UPPER EYELID LOWER EYELID LOWER MUCOSAL EYELID EYEBROW FULL LIP COLOR LIPLINER AREOLAS SCAR CAMOUFLAGE STRETCH MARKS OTHER: Please Initial: I hereby authorize Sharon Cruz to take photographs/video of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising. I have informed Sharon Cruz that I am in good health and not under the care of any physician. I am currently under the care of a physician and I am being treated for the following condition(s): Physician's Name: Phone Number: Address: City/State: Zip: Please Initial: I have been given a copy of after care and acknowledge that failure to follow instructions may result in loss of color,discoloration,infection ect. I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results. I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments.I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment; Page 3 of 8