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NAME CONSFPi R' FORM DR KILLER 11EALI Y BY KATRINA PHONE AGE DOB ADDRESS CITY ---...--STATE- ZIP I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permarient make-up from Katrina Bambula-Santos (thereafter called "Technician") and that all of my ilijestions have been answered to my full and total satisfaction/understanding. Procedure to be performed: _ _ No. OF visits required Cost of Procedure: $ Deposit Paid: Yes__ No Date Rec'd 1 specifically acknowledge that I have been advised of the matters sit forth below and agree as follows: (initial at each line) I have truthfully represented to the Technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge, I do riot have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have a tattoo at this time. i acknowledge that obtaining permanent mak&-up is my choice alone. The application of permanent make-up will result in a permanent change to my appearance and that needles and inks will go into my skin. I understand that after the procedure the actual color of the pigment may be modified slightly, due to the tone and color of my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent make-up to the original condition, and it is very costly to remove. I have been informed of the nature, risks, and pessible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of aDsmetic procedure, including but not limited to: infection, allergic, reaction, scarring, inconsistent color and spreading, fanning or fading of pigments. ALLNQWLEbbE TNA -i' TATiUD INKS 4( E NDT FbL1 taPPl2�VED AND 4I�uLi+� Z-1DNSe]6�UE7-'ALE5 AV -E L NV_Nu VN.