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Y O � LAST F TN ' e LAS 1 1\ 1 1 1 r AGREEMENT 1. ACKNOWLEDGMENT OF RISKS OR COMPLICATIONS ASSOCIATED WITH THE PERMANENT COSMETIC FACIAL TATTOO PROCEDURE A. The Releasee has been informed by the Releasor of the possible dangers which may occur as a result of having a permanent cosmetic facial tattoo procedure performed. The Releasee acknowledges that those dangers may include eye injury from the permanent cosmetic eyeliner procedure, allergies from pigment used in the procedure(s), fever blisters or cold sores from the permanent cosmetic lip procedure, swelling, bruising (although rare), temporary minor bleeding, redness or pinkness, and soreness. The Releasee understands and acknowledges that the permanent cosmetic facial tattoo procedure may permanently alter the appearance of the Releasee's face of which may not be desirable to the Releasee. B. Now, the Releasee having been fully and completely advised of all inherent risks, dangers, and complications which may arise from a permanent cosmetic facial procedure,voluntarily assumes all and any risks, dangers, or complications which may arise as a result of a permanent cosmetic facial tattoo procedure. To help minimize any risks, the Releasee will answer Yes or No to the following conditions in order to describe if the Releasee has any of the following medical conditions. 1. Keloid formation Y N If yes, explain location: 2.Diabetes Y N 3.Alcoholic Y N 4.Epilepsy Y N 5.Under 18 years old Y N If yes,then I have the legal consent of my parent or legal guardian. Signature of parent or legal guardian I.D. 6.Using Accutane Y N If yes,when was the last time? 7.Using Retin-A Y N If yes,location 8.Hemophiliac Y N 9.Pregnant or nursing Y N 10.Active skin diseases Y N List them: 11.Autoimmune Disorders Y N 12.Hepatitis Y N 13.Blood disease Y N 14. Cold sores Y N If yes,obtain a prescription for Zovirax if lip procedure will be done. 15. Herpes Y N 16. Cancer Y N 17. Steroids Y N 18. Chemical Peel Y N If yes,when 19.Using Glycolic Acid Y N What products: What strength of glycolic acid? 20. Other Tattoos Y N Where Any problems 21.Heart condition Y N 22.Allergies to any medications or topical salves, such as Bacitracin,Lanolin,Lidocaine,Novocaine,Metals, Neomycin,Paba,Rubber gloves Y N Name each one: 23.Taking medication Y N Name each one: 24.Any other diseases Y N 25.Taking blood thinners, such as aspirin,Coumadin,Alcohol,or Ibuprofen. Y N..Name each one: 26.Do you use a tanning bed,lamp,or natural sunlight?Please circle one.