COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

Versailles Salon PR0541621 1010 Central Ave.Tracy CA, 95367 March 3, 2025 Correction Photo 5: Client consent forms including other potential risk factors for Blooborne Pathogen Versailles Salon And Spa IOlil Central Ave* Tra CA 95376• Salon 209 83fr1505 Cell 27 l"Ure and Consent for Tattoo and Dermal P-duree(continued)... wever,spot testing does not identify individuals who may have a delayed allergic ee to(circle one): RECEIVE WAIVE a spot test prior to application and I agree to release Ve sistants and pigment manufacturer(s)from any and all liability related to allergic react ction to applied pigments_ I have been told that allergic reactions to pigment are very rare,however,they car In they occur they can be serious and especially difficult and very troublesome to trea 1 have been told that this procedure may involve pain and discomfort. I understand the markings are permanent I have been told that a follow up procedure will be required. I am 18 years of age I understand there are other potential risk factors for blood born pathognes. Other risks involved with the procedure may include,but not limited to:infection action(s)to applied pigments,allergic and other reaction(s)to products applied during ocedure,fanning or spreading of pigment(pigment migration),fading of color and oth 1 accept full responsibility for any and all,present and future,medical treatment(s cur in the event I need to seek treatment(s)for any known or unknown reason associa fanned for me- ]have been given an opportunity to ask questions about the procedures and the p d the risks and haasrds involved and I believe that I have sufficient information to give nsetrt- I have agreed that should I have a complaint of any kind whatsoever,I shall Versailles Salon And Spa and I further agree that any controversy or claim arising ont of or relating to this consent contract between myself and Versailles Salon And Spa r the breach thereof,shall be settled by arbitration in the state of C'aliforrtta in accordance e American Arbitration Association and judgment of the award rendered by the arbitrate n any court having iurisdiction thereof. I understand that if I have an infection.adverse reaction or allergic reaction to the notify Versailles Salon And Spa a health care practitioner,California Department of Health,Drugs and Medical Devices Di I certify this form has been fully explained to me and I have read it or it has been re nderstand its contents. explain La ve ave received a copy of the Post Procedure Instructians.It has been fully read it or it has been read to me.I understand its content' Date SigrtatUr`e Medical History Form Birth date: Today"Date• Nacre- Ve�ealllea 2\neekmp\2P17 REVISES Canetn,Fnrm TFM1P1-ATr`ERICA'd�a��t�.!/2O Alexander Cruz 5