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755 South Fairmont Ave. Suite E-2, Lodi Ca. 95240 Disclosure and Consent for Tattoo and Dermal Procedure as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. You have described the recommended procedure to be used as Scalp Micropigmentation a form of Permanent Makeup. The practitioner utilizing one or more very fine needles to deposit colored pigment or ink into the outer layer of the epidermis on the scalp of the subject to appear as if a healthy hair follicle exists in a normal growth pattern. Performed properly it creates the illusion of hair. Scalp Micropigmentation is a form of tattooing and the markings are permanent. Initial: I understand that there are no tattoo or permanent makeup pigments that have been approved by the Federal Food and Drug Administration. The health consequences of using these products is unknown. I voluntarily request as my intradermal Cosmetic Technician to deem necessary to perform on my body the Scalp Micropigmentation procedure. I hereby authorize Lodi Micro Clinic, to take photographs of the work performed both before and after treatment to be maintained only in my file. I hereby authorize Lodi Micro Clinic, the use of said photographs to be used for purpose of advertising. I have informed Lodi Micro Clinic, that I am in good health and not under the care of a physician. I am currently under the care of a physician and I am being treated for the following condition(s): I understand that this description of the procedure is simply an effort to make me better informed so that I may give or withhold my consent for this procedure. I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results. I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment.