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___________I have informed ______________ that I am in good health and not <br />under the care of any physician. <br />___________I am currently under the care of a physician and I am being treated <br />for the following condition(s)_________________________________________ <br />Physician’s Name:___________________ Physician’s Phone:_______________ <br />Address: __________________________City/State: _________ Zip: ________ <br /> <br />Please Initial: <br />______I have been given a copy of after care and acknowledge that failure to <br />follow instructions may result in loss of color, discoloration, infection, etc. <br />______I have been told that there may be known and unknown risks and hazards <br />related to the performance of the procedure planned for me and I understand that <br />no warranty or guarantees have been made to me as to the results. <br />______I acknowledge the manufacturer of the pigment to be applied requires spot <br />testing and specifically disclaims any responsibility for any adverse reaction to <br />applied pigments. I understand spot testing may identify individuals who develop <br />an immediate allergic reaction to pigment. <br />______However spot testing does not identify for individuals who may have a <br />delayed allergic reaction to the pigment. I agree to (circle one): <br />RECEIVE WAIVE A spot test prior to application and I agree to <br />release _________, assistants and pigment manufacturer(s) from any and all <br />liability related to allergic reaction or any other reaction to applied pigments. <br />_______I have been told that allergic reactions to pigment are very rare, however, <br />they can and do occur and when they occur they can be serious and especially <br />difficult to treat. <br />_______I understand the markings are permanent and that there is a possibility of <br />hyper pigmentation resulting from a procedure, especially in individuals prone to <br />hyper pigmentation from a scar or other injury.