CLIENT CONSENT FORM

Ann's Browology LLC

Kindly complete the Consent Form below prior to your appointment:

First name

Last name

Appointment date

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

I am over the age of 18, not currently under the influence of drugs or alcohol, nor have I been in the last 24 hours, and I wish to have cosmetic or body tattoos performed. The details of the specific procedure have been explained to me, and I have had the opportunity to read and understand the documents provided. I understand that I can ask questions about the procedure at any time, and I am voluntarily seeking these 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.

Yes

Only Tattooed Area

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 equipment 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.

I have read the above statement

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

Please specify the area of your tattoo (e.g., eyebrows, lips, inner forearm, upper back, etc.)

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. (Please make sure to eat well before the appointment)

Yes

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

Yes

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

Yes

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

Yes

History of skin cancer at site of service.

Yes

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

Yes

History of epilepsy, seizures, fainting or narcolepsy.

Yes

History of eye disease.

Yes

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

Yes

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

Yes

History of jaundice or keloid formation.

Yes

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

Yes

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

Yes

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

Client refuses to disclose infromation listed.

Yes

Client's Signature:

Signature field is empty.

Artist name: AN PHAN

Certification Number: 1681

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