CLIENT CONSENT FORM

Ann's Browology LLC

Please fill out the following form.

First name

Last name

Phone

Email

Date of birth

Address

Date of the treatment

I, am over the age of 18, am not currently under the influence of drugs or alcohol or have been in the last 24 hours, and desire to have cosmetic or body tattos performed. The details of the specific procedure to be performed has been explained to me, have had the oppertunity to read and understand the documents presented, understand that at any time I can ask about the procedure and I am voluntarily obtaining services of my own free will and volition.

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of procedure, including but not limited to: infection, allergic reaction, scarring, inconsistentcolor, and spreading, fanning or fading of pigments.

I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the tattoo procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure.

I understand that while cosmetic tattoo is referred to as semi-permanent in nature, due to each individual’s reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent.

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo. I acknowledge some of these potential adverse changes may not be correctable.

I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician.

I understand that the taking of before and after photographs of the said procedure are a condition of such procedure. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and the procedure process. I accept full responsibility for the decision to have this tattoo work done.

I give permission to use of my photos for the purpose of marketing. My pictures may appear in print or online.

I understand that Salon Lofts LLC shall not be responsible or liable for any damage or losses to occur from any procedure at Ann’s Browology LLC

Risk, Effects, and Permanence: A tattoo is a permanent mark or design made on skin with pigments that are inserted by needles piercing the top layer of the skin repeatedly. Body art procedures may cause slight bleeding and pain. Because body art procedures breach the skin, infections and other complications are possible. In some people, tattoo pigments can cause allergic skin reactions. Infections can occur from use of unsterile equip- ment or not following proper aftercare. A procedure done contaminated equipment may cause the contraction of various blood-borne diseases such as hepatitis B, and HIV. Other skin problems such as granulomas (nodules that may form around material the body perceives to be foreign) or keloids (raised areas caused by an overgrowth of scar tissue) can occur for certain people. Tattoo can cause complications with MRI (magnetic resonance imaging) procedures such as an interference with the image

Please describe the location of your tattoo or the permanent makeup service you have:

A copy of the Clients photo identification must be included on file. Examples of valid identification include passport, State identification or Drivers License

Please upload your ID photo here

Client Health Questionnaire: By signing below, I acknowledge that I have been asked about the following conditions by my Body art practitioner, and I have honestly and correctly indicated if I do or do not fall into any of the risk cate- gories to the best of my knowledge, and have been provided with additional, applicable information. Client should consult a physician prior to the procedure if there are any concerns related to the conditions below as the risk of the health conditions listed may increase with the body art procedure.

Has eaten within the last 4 hours

Yes

No

History of hemophilia or excessive bleeding or any other blood clotting abnormalities

Yes

No

Diabetes or other conditions which may affect blood circulation and/or ability to fight infection and or affects the clients neurological system

Yes

No

History of skin disease, skin lesions, or skin sensitivities to soaps or disinfectants

Yes

No

History of skin cancer at site of service

Yes

No

History of allergies, anaphylactic reaction, or adverse reactions to latex, pigments, dyes, disinfectants, metals or other sensitivities related to body art procedures

Yes

No

History of epilepsy, seizures, fainting or narcolepsy

Yes

No

History of eye disease

Yes

No

Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting (such as arfarin, XareltoTM, Plavix, EliquisTM, etc)

Yes

No

Current pregnancy and/or breast-feeding in the last three months

Yes

No

History of jaundice or keloid formation

Yes

No

History of AIDS or positive of HIV test Hepatitis B, Hepatitis C

Yes

No

History of any known medical condition which would increase susceptibility to infection or impair the healing process (e.g. immunosuppression, etc.)

Yes

No

Any other information that would aid the body art technician or any other individual involved in providing education on the client’s suitability for receiving a body art procedure and the client’s body healing process

Yes

No

Client refuses to disclose infromation listed

Yes

No

I declare that the info I’ve provided is accurate and complete.

Client's Signature

Body art artist’s name: An Phan

Certification number: 1681

Fulton County Health Department Phone: (404) 613-8150

CLIENT CONSENT FORM

Ann's Browology LLC

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