Permanent Make-Up Release Form

Ask a staff member what to enter
Today's Date:
Tue Apr 13 2021 01:58
Practioner:*
Procedure:*
Dead Rockstar Permanent Make-Up Consent Form
Please read and answer
Age*
I have been truthful in representing my age as at least 18 (eighteen) years of age to the associates, agents, employees, and representatives of Dead Rockstar. If I have knowingly misrepresented my age and/or identity Dead Rockstar may prosecute me to the fullest extent of the law.
Duress*
I am not under the influence of alcohol, drugs, or controlled substance and I am voluntarily submitting to have permanent make-up done without duress or coercion. It is my choice alone and I consent to any procedures, conduct, and/or actions that take place to perform the procedure.
Risks and/or Reactions*
I acknowledge that cosmetic tattooing is an art form and the results cannot be guaranteed or completely predicted. No representation or guarantee has been made to me as to specific results of cosmetic tattooing which results may be different from what I expect. I understand that it is not entirely predictable as to my body's reaction and there is a possibility or eyelid irritation with eyeliner tattooing and a potential for infection, allergic reaction, local irritation or corneal injury with any permanent make-up procedure. I also understand that if I have had the COVID-19 vaccine that there is a possibility of a reaction from my procedure.
Permanent*
I understand that permanent make-up 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. I also acknowledge that permanent make-up is considered make-up enhancement and is not intended to totally replace conventional make-up.
Aftercare*
The Artist and Dead Rockstar have given me instructions on the care of my permanent make-up while it's healing and I understand them and will follow them. I acknowledge that it is possible that the site can become infected, particularly if I do not follow the instructions given to me. If any touch-up work is needed due to my own negligence, I agree that the work will be done at my own expense.
Fading*
I acknowledge that permanent make-up fades or softens approximately 10-20% during the first week after initial treatment. It may heal patchy or irregular after the initial treatment and that is why a 2nd visit is often, but not always, necessary. I also understand that facial products containing AHAs, retinoids, retinols and any chemical that will lighten my skin will also lighten my tattoo. In addition, I agree to use sunblock on eyebrows when exposed to intense sunlight or tanning beds.
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 Dead Rockstar.
Legal Action*
I agree to reimburse each of the Artist and Dead Rockstar for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or Dead Rockstar and in which either the Artist or Dead Rockstar is the prevailing party. I agree that the courts of Cass County, North Dakota 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.
Waive*
TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and Dead Rockstar 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 Dead Rockstar, or otherwise.
COVID-19*
I understand that it is at my own risk to receive services from Dead Rockstar during the COVID-19 pandemic and will not hold Dead Rockstar responsible for any illness resulting from or related to the COVID19 pandemic nor will I take any legal action.
Y
N
COVID-19*
Have you had contact with anyone with confirmed COVID-19 in the last 14 days? Do you have any of the following symptoms: fever, chills, repeated shaking with chills, cough, headache, shortness of breath (not severe), muscle pain, sore throat, new loss of taste or smell? If yes please provide details.
Details:
 

Y
N
Bloodbourne Pathogens*
Do you have any communicable diseases such as Hepatitis A, B, or C, HIV, AIDS, or contagious diseases such as Tuberculosis, Mononucleosis, Pneumonia, or STDs/STIs? (It's okay if you do, we just want to know for our and other's safety). If yes please provide details.
Details:
 

Y
N
Allergies*
Are you allergic to nickel, iodine, latex or anything else that could cause skin rash, anaphylactic shock, or requires immediate medical attention? If yes please provide details.
Details:
 

Y
N
Medical Conditions*
Do you have any of the following: diabetes, epilepsy, hemophilia, a heart condition, or take blood thinning medication? Do you have any other condition that may interfere with the application or healing of the tattoo? Are you the recipient of an organ or bone marrow transplant and, if you are, have you taken the prescribed preventive regiment of anti-biotics that is required by your doctor in advance of any invasive procedure such as a tattoo? Are you pregnant or breastfeeding? Do you have a mental impairment that may affect your judgment in getting the tattoo? If yes please provide details.
Details:
 

Y
N
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 select yes please advise your Artist).
 
How did you hear about us?*
 

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.
Name:*
Address:*
Date of birth:*
You must be 18 or older
Phone #:*
Email:*
Signature:*


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