Micropigmentation Release Form
Let us do this part
Today's Date:
Fri Aug 14 2020 05:30
Artist:*
glo facial spa & skin center, LLC
203 1/2 W. North St., Normal, IL 61671
2111 W. Park Ct., Champaign IL 61821
309-808-2805
309-846-4045 text

brenda@glofacialspa.com
Please read & answer
 
What procedure are you having?*


 
How did you hear about us?*
 

Eaten*
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.
Payment*
We accept cash, local check or all credit cards. Fees include initial procedure and one focus visit 6 month later. Additional fees are required if your skin needs additional focus visit or you decide to alter the pigmented area (add shading, strokes, widen, deepen color intensity, etc)
 
What to Know Before Getting a Tattoo*
While a tattoo may only take a few minutes to acquire, it is permanent. You should understand the risks and research the process before getting a tattoo. Tattooing involves breakin the skin, one of your body's main protective barriers. Ths means you may be more susceptible to skin and blood infections. Specific risks include:

Bloodborne diseases. If the equipment used to do your tatoo is contaminated with the blood of an infected person, you can contract a number of serious bloodborne diseases. These include hepatitis C, hepatitis B, tetanus and HIV, the virus that causes AIDS.

Skin infections. The use of unsterile equipment or re-used ink can result in skin infections, ranging from minor to potentially serious antiibiotic resistant infections Symptoms may include redness, swelling, or pus-like drainage

Granulomas. Bumps may form around the site of the tattoo as a reaction to the ink.

Scars and keloids. The ink may cause scars and keloids (raised, ridged areas caused by overgrowth of scar tissue).

Allergic reactions. The ink may cause an itchy rash at the tattoo site.

Swelling or burning. Tattooed areas may swell or burn during Magnetic resonance imaging (MRI) exams.

Additional topics to discuss with your body art professional include their Bloodborne Pathogen Training, the establishment's proficiency requirements, and the establishment's autoclave monthly spore test results.

If abnormal itching, irritation, redness, swelling or fever should appear, please contact a physician immediately. These could be signs of a potentially serious medical condition that should be addressed.

To ensure that your body art procedure heals properly, we ask that you disclose if you have or have had any of the following conditions. Disclosure does not legally prevent you from having a body art procedure.

Diabetes, History of hemophilia (bleeding), History of skin diseases, skin lesions, or skin sensitivities to soaps, disinfectants, numbing agents, pigments, dyes or other skin sensitivitees such as latex.

History of epilepsy, seizures, fainting or narcolepsy

Use of medications, such as anticoagulants that thin the blood and/or interfere with blood clotting

Human immunodeficiency virus (HIV)

Hepatitis

Please list any information that might be relevant to your body art procedure:
 

Waive*
TO WAIVE AND RELEASE to the fullest extent permitted by law 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 tattoo, whether caused by the negligence or fault of either the Artist or the Tattoo Studio, or otherwise.
Bloodbourne Pathogens*
Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety).
Healing*
The Artist and the Tattoo Studio have given me instructions on the care of my tattoo while it's healing, and I understand them and will follow them. I acknowledge that it is possible that the tattoo 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.
Health*
I do not have diabetes, epilepsy, hemophilia, a heart condition, 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 preventive anti-biotics. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.
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.
Design*
I have discussed the shape of the pigmented area and have given my consent to the design, shape of the area to be tattooed. I understand that removal may be difficult if not impossible after the area is pigmented.
Fading*
.I understand that color may heal differently in my skin and that certain medications and my own lymphatic system may determine the outcome of my tattoo. I also understand that over time, the colors and the clarity of my tattoo will fade due to natural dispersion of pigment under the skin and due to certain cosmetics and the effects of the sun.
Permanent*
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.
Legal Action*
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 the Tattoo Studio and in which either the Artist or the Tattoo Studio is the prevailing party. I agree that the that the courts of Illinois in the United States of America shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.
Questions*
I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions have been answered, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the Tattoo Studio.
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 do not tick this provision, please advise your Artist).
 
Medical*
Please advise if you are currently under the Dr. Care for any condition and list all medications and supplements you are currently taking or have taken in the last month.
 

Consent*
I understand that the procedure of Micro Pigment Implantation is the process of implanting micro insertions of pigment into the dermal layer of skin. Micro pigment Implantation is a a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.

I voluntarily request as my intradermal cosmetic technician, and such association and technical assistance as she may deem necessary to perform on my body the procedure.
spot testing*
I acknowledge the manufacture of the pigment to be applied recommends 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 reaction to a pigment; however, spot testing does not identify individuals who may have a delayed allergic reaction to pigment.

I agree to waive a spot test prior to application and I agree to release Brenda Berndt, assistants and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments.
spot testing
In light of the above paragraph, I choose to receive a spot test prior to pigment application.
risks*
I understand there is a possibility of hyperpigmentation or hypopigmentation from a procedure, especially in individuals prone to this from a scar or other injury. Other risks may include, but not limited to: fanning or spreading of pigment (pigment migration) or other unknown risks.
notification*
I have agreed that should I have a complaint of any kind, I shall immediately notify Brenda Berndt and I further agree that any controversy or claim arising out of or relating to this consent and/or signed contract between myself and or the breach thereof, shall be settled in arbitration in the state of Il. in accocrdance with the Rules of the American Arbitration Association and judgement of the award rendered by the arbitrator(s) may be entered in any court having jurisdiction therof.
notification*
I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Brenda Berndt a health care practitioner, IL Department of Health, Drugs, and Medical Devices Division.
informed*
I certify this form has been fully explained to me and I have read it or it has been read to me. I understand its contents. I have received a copy of the Post Procedure Instructions. it has been fully explained to me and I have read it or it has been read to me. I understand its contents.
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.
Personal Info
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Address:*
Date of birth:*
If you are under 18 your parent/guardian
Gender:
Nationality:
Phone #:*
Email:*
Signature:*


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