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9 0 <br /> 1 understand that a spot test does not identify individuals who may have a delayed allergic <br /> reaction to the pigment. I agree to a SPOT TEST (CIRCLE ONE): <br /> RECEIVE WAIVE <br /> I agree to release Lodi Micro Clinic and pigment manufacturer(s) from any and all liability <br /> 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, they can and do <br /> occur. And when they occur they can be serious and especially difficult and very troublesome to <br /> treat. <br /> I have been told that this a procedure will involve pain and discomfort. <br /> I have been told that a follow up procedure may be required. <br /> Other risks involved with the procedure may include, but not limited to: infections, allergic <br /> and other reaction(s)to products applied during and after the procedure, fanning or spreading of <br /> pigment, fading of color and other unknown risks. <br /> I accept full responsibility for any and all, present and future medical treatment(s) and <br /> expenses I may incur in the event I need to seek treatment(s)for any known or unknown reason <br /> associated with the procedure. <br /> I have been given an opportunity to ask questions about the procedures. I am aware of the <br /> risks and hazards involved. I have sufficient information to give this informed consent. <br /> I understand that if I have an infection, adverse reaction or allergic reaction to the <br /> procedure, I must notify Lodi Micro Clinic and a health care practitioner. <br /> I certify this form has been fully explained and that I understand its contents. <br /> Signature Date <br />