|
<br />
<br />Microblading & Tattooing by Mimi Chaves
<br />Diva’s Salon & Spa – 801 South Ham Lane, Lodi, CA 95242
<br />Cell: (805) 260-2329, Email: mjcmicroblading@gmail.com
<br />
<br />Page 2 of 5
<br />
<br />MICROBLADING & COSMETIC TATTOOING
<br />CLIENT CONSENT & LIABILITY WAIVER
<br />
<br />Customer’s Name: _______________________________Date: _____________________
<br />I, ____________________ consent to and authorize Marian Chaves of Diva’s Salon & Spa to perform
<br />multiple treatments, microblading and tattooing procedures and related services on me.
<br />A brief description on what has been explained to you. As a customer, you have the right to be informed
<br />about your treatment so that you can make the decision whether to proceed microblading and/or
<br />tattooing or decline after knowing the risks involved. This disclosure is to help inform you, prior to your
<br />consent of treatment about the risks, side effects and possible complications related to microblading and
<br />cosmetic tattooing.
<br />Customer’s
<br />Initials
<br />It has been explained to me that the procedure to be used on me is referred to as Micro
<br />pigmentation (the process of implanting micro-deposits of pigments into the epidermal layer of
<br />the skin). Micro-pigmentation is a form of tattooing used for the purpose of semi-permanent
<br />cosmetic makeup, and for skin imperfection camouflage tattoo coverup.
<br />
<br />I realize the procedure will most likely result in semi-permanent and possible irreversible color
<br />change in the skin area treated. Tattooing can be a permanent. In rare, some possible
<br />complications resulting from this procedure may include infection, scarring, swelling, bruising,
<br />numbness, post procedure discomfort, allergic reaction to pigments and/or anesthetic agents
<br />(topical).
<br />
<br />I understand the practice of this procedure is NOT an exact science. Colors may not match
<br />perfectly or appear exactly as expected. Over the weeks, months and year following the
<br />procedure, softening, fading or change of color of the pigment may occur.
<br />
<br />I understand that there is a possibility of hyper-pigmentation resulting from this procedure.
<br />I have been told that this procedure might involve some pain and discomfort.
<br />I understand that no warranty or guarantees have been made to me as to the result of this
<br />procedure.
<br />
<br />Procedure Description: This procedure involves the insertion of pigment into the dermal layer
<br />of the skin using a sterile, single-use needle or blade to create a permanent or semi-permanent
<br />design. Depending on the type of tattooing (cosmetic or body art), this may include shaping and
<br />coloring areas such as the eyebrows, eyeliner, lips, or body. The procedure may cause minor
<br />discomfort, swelling or redness, and healing typically occurs over 7-14 days. Touch-up sessions
<br />may be required for best results.
<br />Tattooing and body art can be permanent.
<br />Please note that the tattoo inks, dyes, and pigments have not been approved by the federal Food
<br />and Drug Administration and that the health consequences of using these products are unknown.
<br />
<br />I understand that there will be “before and after” pictures will be taken of your eyebrows and used
<br />for marketing purpose. Your face will not be part of the images.
<br />
<br />I have been given the opportunity to ask questions about the procedure and the risks involved. I
<br />am aware that infections can include an odor coming from the brow area and a greenish or
<br />brownish discharge. If the infection becomes serious, the swelling may extend to the eyelids and
<br />the redness to the scalp or neck. If this happens, I understand I am to seek medical attention.
<br />
<br />The full amount is due at the beginning of the service. Payment is due in cash or PayPal. NO
<br />REFUNDS NO EXCEPTIONS.
<br />
<br />I understand that the description of the procedure is not meant to scare or alarm me. It describes
<br />the procedure so I may make an informed decision to proceed or refuse the procedure. In
<br />consideration of having the service provided by Marian (Mimi) Chaves, I fully release and
<br />discharge, without limitation, from any and all claims, losses, demands, rights of cause of action;
<br />damages or injuries to my person or property, present or future, whether known, anticipated or
<br />unanticipated, that may occur from any cause whatsoever, whether based on tort, contract,
<br />products liability, or other theory of recovery. As a result of or airing out any treatment or surgery
<br />that may arise from any treatment or procedure by Marian (Mimi) Chaves including, but not
<br />limited to, any claims for consequences, and known and unknown developments of any such
<br />injuries, and claims with respect to the nature, extent, and permanency of any such injuries.
<br />
<br />I understand and agree to the above.
<br />
<br />Printed Name Phone Number
|