Laserfiche WebLink
INFUSION SMP, LLC <br />Sarah M. Williams, Artist and Partner <br />Faustino Cruz, Artist and Partner <br /> <br /> <br />1150 W. Robinhood Dr. <br />Suite 2B <br />Stockton, CA 95219 <br /> <br /> <br /> Informed Consent and Release Form <br />Please read and initial each statement below: <br />______ I agree to pay ______________ for my micropigmentation procedure, which <br />shall be due and payable upon completion of this agreement. I understand that the <br />amount for this procedure is nonrefundable. <br />______ I have been fully informed of the inherent risks, associated with <br />micropigmentation (i.e. tattoo) treatment. I fully understand this is a tattoo process and <br />therefore not an exact science. I request the permanent skin pigmentation procedure <br />and accept the permanence of the procedure as well as the possible risks, <br />complications and consequences of the said procedure. I fully understand that these <br />complications and risks, known and unknown, can lead to injury, including but not <br />limited to infection and scarring. Having been informed of the potential risks associated <br />with getting this procedure, I still wish to proceed with the permanent micropigmentation <br />application and I freely accept and expressly assume any and all risks that may arise <br />from permanent micropigmentation. <br />______ I am at least 18 years of age and have a valid I.D. <br />______ I hereby consent to the above procedure being done on me and in <br />consideration of their doing so, I hereby and forever discharge, waive and/or release to <br />the fullest extent permitted by law each of Sarah M. Williams and/or Faustino Cruz, <br />hereafter identified as “Artist”, and/or Infusion SMP, LLC, its officers and employees <br />from all liability whatsoever, for any and all claims or causes of action that I, my estate, <br />heirs, executors or assigns may have for personal injury or otherwise, including any <br />direct and/or consequential damages, which result or arise from the application of my <br />permanent micropigmentation, whether caused by the negligence or fault of either Artist <br />or Infusion SMP, LLC, or otherwise.