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SR0087001
Environmental Health - Public
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4100 – Safe Body Art
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SR0087001
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Entry Properties
Last modified
9/1/2023 11:28:31 AM
Creation date
9/1/2023 9:50:15 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
SR0087001
PE
4103
FACILITY_NAME
MY SALON SUITES
STREET_NUMBER
5759
STREET_NAME
PACIFIC
City
STOCKTON
Zip
95207
ENTERED_DATE
7/27/2023 12:00:00 AM
SITE_LOCATION
5759 PACIFIC B145
QC Status
Approved
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SJGOV\cfield
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EHD - Public
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I ACKNOWLEDGE & UNDERSTAND THAT THE PIGMENT IMPLANTED ON <br />DARKER SKIN TYPES (I.E. INDIAN, AFRICAN AMERICAN, FILIPINO, <br />ETC.) THE PIGMENT WILL APPEAR SOFTER AND BLEND MORE WITH <br />YOU OWN SKINS MELANIN (TONES) AND WILL NOT APPEAR AS BOLD <br />OR DEFINED AS ON LIGHTER SKIN TYPES. ..... <br />o ALOPECIA CLIENT: DUE TO THE CHANGE IN SKIN TEXTURE, <br />PIGMENTS MAY WILL HEAL POWERED._____ <br />1 ACKNOWLEDGE THAT THE PROCEDURE WILL RESULT IN A <br />PERMANENT CHANGE TO MY APPEARANCE AND THAT NO <br />REPRESENTATIONS HAVE BEEN MADE TO ME AS TO LATER CHANGE <br />OR REMOVE THE RESULTS_ <br />I UNDERSTAND THAT SKIN ALTERING PROCEDURES, SUCH AS <br />PLASTIC SURGERY, IMPLANTS AND/OR INJECTIONS MAY ALTER <br />AND DEGRADE MY PERMANENT MAKE-UP. I FURTHER UNDERSTAND <br />THAT SUCH CHANGES ARE NOT THE FAULT OF THE PRACTITIONER. <br />I FUTHER UNDERSTAND THAT SUCH CHANGES IN MY APPEARANCE <br />MAY NOT BE CORRECTABLE THROUGH FURTHER PERMANENT <br />MAKE-UP PROCEDURES.__ _ <br />THYROID CONDITIONS AND MEDICINES CAN/WILL PREVENT THE <br />PIGMENT FROM RETAINING, FADE QUICKLY, BLUR, OR CHANGE IN <br />COLOR. I ACCEPT THESE POTENTIAL RISKS AND WISH TO <br />PROCEED._____ <br />. I ACCEPT FULL RESPONSIBILITY FOR DETERMINE THE COLOR <br />SHAPE AND POSITION OF THE BROWS. ONCE SHAPE IS APPLIED IT <br />CANNOT BE CHANGED._ <br />I UNDERSTAND THE ACTUAL COLOR OF THE PIGMENT MAY VARY <br />DUE TO THE TONE AND COLOR OF MY SKIN. _____ <br />. IN THE EVENT OF A CAT OR MRI SCAN, PLEASE INFORM YOUR <br />PHYSICIAN OF YOUR IRON OXIDE PERMANENT COSMETICS AS <br />SOME PULLING OR BURNING SENSATION (RARE) MAY OCCURE <br />DURING THE PROCEDURE._____ <br />. PERMANENT COSMETIC INK IS NOT FDA APPROVED AND HEALTH <br />CONSEQUENCES ARE UNKNOWN. ______ <br />PERMANENT MAKEUP IS AN ART NOT SCIENCE. CLIENT'S RESULTS <br />VARY FROM PERSON TO PERSON._____ <br />WRITTEN AFTER-CARE INSTRUCTIONS AND KIT HAVE BEEN <br />GIVEN____ <br />I RELEASE THE RIGHT TO ANY PHOTOGRAPHS TAKEN OF ME AND <br />THE TATTOO AND GIVE CONSENT IN ADVANCE TO THEIR <br />REPRODUCTION IN PRINT OR ELECTRONIC FORM. (FOR <br />ASSURANCE, IF YOU DO NOT INITIAL THIS PROVISION, PLEASE <br />INFORM ADORN BEAUTY INK LLC NOT TO TAKE ANY PICTURES OF <br />YOU AND YOUR COMPLETED TATTOO).______ <br />. I AGREE THAT ADORN BEAUTY INK LLC HAS A NO REFUND POLICY <br />ON TATTOOS______ <br />ADORN BEAUTY INK <br />
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