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_______I have been told that a follow up procedure may be required. <br />_______I have been told that further touch ups needed will not be covered and an <br />additional cost may occur. <br />_______I have been told that there is a chance that I may experience a corneal <br />abrasion. <br />_______Other risks involved with the procedure may include, but not limited to: <br />infections, allergic and other reaction(s) to applied pigments, allergic and other <br />reaction(s) to products applied during and after the procedure, fanning or spreading <br />of pigment (pigment migration), fading of color and other unknown risks. <br />_______I accept full responsibility for any and all, present and future, medical <br />treatment(s) and expenses I may incur in the event I need to seek treatment(s) for <br />any known or unknown reason associated with the procedure planned for me. <br />_______I have been given an opportunity to ask questions about the procedures <br />and the procedure to be used and the risks and hazards involved, and I believe that <br />I have sufficient information to give this informed consent. <br />_______I have agreed that should I have a complaint of any kind whatsoever, I <br />shall immediately notify ___________,and I further agree that any controversy or <br />claim arising out of or relating to this consent and/or any signed contract between <br />myself and Practitioner or the breach thereof, shall be settled by arbitration in the <br />state of in California with the Rules of the American Arbitration Association and <br />judgment of the award rendered by the arbitrator(s) may be entered in any court <br />having jurisdiction thereof. <br />_______I understand that if I have an infection, adverse reaction or allergic <br />reaction to the procedure, I must notify and my health care <br />provider. <br />_______I certify this form has been fully explained to me and I have read it or it <br />has been read to me. I understand its contents. <br />_______I have received a copy of the Post Procedure Instructions. It has been fully <br />explained to me and I have read it or it has been read to me. I understand its <br />contents. <br />Signature___________________________ Date________________