Consultation + Release Form

Let us do this part

Today's Date:

Thu May 2 2024 12:35

Practitioner:*

Please read and answer

NO PERSON MAY BE TATTOOED WHO APPEARS TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS

Influence*

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist without duress or coercion.

Do you have previous eyebrow/eyeliner tattooing?*

If yes, when?

Details:

Skin Type?*

Are you pregnant or breastfeeding?*

History of Keloids or Hypertrophic scarring?oids or Hypertrophic scarring?*

If yes, explain:

Details:

Any known allergies to Lidocaine, Benzocaine, or Tetracaine?*

Topical anesthetics are used to numb the area that will be microbladed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and Epinephrine in a cream or gel form are typically used I confirm that I am not allergic to any of these products.

Botox, chemical peels, or any other treatments to eyebrow/face area in the last 3 months?*

If yes, explain:

Details:

Do you have any Bloodborne Pathogens, std's, viral infections or diseases?*

It's okay if you do we just need to know for our and others safety. Your privacy is key, we do not disclose this information to anyone.

Are you a diabetic? (Doctors written clearance required at time of appointment)*

Skin irritations or Psoriasis near the treated area?*

(rashes, sunburn, acne, etc.)

Are you currently or have you undergone chemotherapy?hemotherapy?*

Details:

History of Epilepsy?*

Accutane in the past year?*

Do you have a pacemaker or major heart problems?*

Are you currently taking any medications?*

If yes, list ALL:

Details:

Have you eaten in the last 4 hours?*

It is a good idea to eat beforehand to increase sugar levels. If you haven't, let us know and feel free to grab a snack while you wait!

Do yo have any allergies we should be aware of?*

Details:

Health*

I do not have epilepsy, hemophilia, nor do I take blood thinning medication. I do not have any other condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant, or, if I am, I have taken the preventative antibiotics. I do not have a mental impairment that may affect my judgment.

Touch up*

I have been advised that a touch up session is needed to make any adjustments to shape and color and to fill any pigment or ink that may have had poor retention. Touch ups must be completed within 60 days of initial procedure. After 60 days the touch up will be considered a color boost of $150.

Tanning/Products*

I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup. Successful color saturation can not be guaranteed due to hidden scar tissue. Implanted ink/pigment can slightly change over time due to circumstances beyond my control and I will need to maintain the color with future applications and a touch up session within 60 days

Inks*

I understand that tattoo inks, dyes, and pigments have not been approved by the Federal Food and Drug Administration (FDA) and that the health consequences of using these products are unknown. I am aware that there is a possibility of an allergic reaction to the pigments or other materials used.

Anti-Aging/Acne Products*

I understand that Retinal-A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color and cause premature exfoliation of the pigment. Laser hair removal, plastic surgery, or any other skin altering procedures may result in adverse changes to the permanent cosmetics. I acknowledge these may not be correctable.

Risks*

I have been informed of the inherent risks and dangers associated with getting a tattoo. I fully understand that these risks, know and unknown, can lead to injury including but not limited to possibility of discomfort or pain, infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex gloves, and/or soap. Having been informed of the potential risks, I still wish to proceed with the tattoo application and I freely accept and expressly assume any and all risks.

Waive & Release*

I WAIVE AND RELEASE to the fullest extent permitted by law to each of the Artist and the Studio from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise including any direct and/or consequential damages, which result or arise from my procedure, whether caused by the negligence or fault of the Artist or Tattoo Studio or otherwise.

Aftercare*

The Artist and Tattoo Studio have given me instructions on the care of my tattoo while it is healing and I understand them and will follow them. I acknowledge that it is possible that it can become infected, particularly if I do not follow the instructions given to me. If any touch-up work to the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

Attorney*

I agree to reimburse each of the Artist and the Tattoo Studio for any attorneys fees and costs incurred in any legal action I bring against either the Artist or Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party.

Questions*

I acknowledge that I have been given adequate opportunity to read and understand this document and that any and all of my questions have been answered. I understand that I am signing a legal contract waiving rights to recover against the Artist or Tattoo Studio.

Age Verification*

I am Eighteen (18) years of age or older in accordance with Texas State Law with my state or government issued identification card present.

Photography*

I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. If you select NO to this please advise the Artist.

Permanent*

I understand the permanence of the markings and that a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means which can be disfiguring and or costly and which in all likelihood will not result in the restoration of my skin.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:*

Address:

Postcode:

Date of birth:*

You must be 18 or older

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.

Enter passcode to submit: