Disclosure and Consent for Tattoo and Dermal Procedures

I, _______________________________, as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure.

You have described the recommended procedure to be used as Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin. Micro pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.

I voluntarily request as my intradermal cosmetic technician, Debra Rasberry and such association and technical assistance as she may deem necessary to perform on my body the following procedure (circle one):

UPPER EYELID LOWER EYELID LOWER MUCOSAL EYELID EYEBROW FULL LIP COLOR LIPLINER AREOLAS SCARCAMOUFLAGE STRETCH MARKS OTHER:

Please Initial:

______ I hereby authorize Debra Rasberry to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.

_______I hereby authorize Debra Rasberry to take photographs of the work performed both before and after treatment to be maintained only in file.

_______I have informed Debra Rasberry that I am in good health and not under the care of any physician.

_______I am currently under the care of a physician and I am being treated for the following condition(s):

Physician’s Name: _______________________ Phone Number: __________________

Address: _______________________ City/State: __________________ Zip: ______________

Please Initial:

_______I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure.

_______I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results.

_______I acknowledge the manufacturer of the pigment to be applied requires 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 allergic reaction to pigment; however, spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to (circle one):

RECEIVE _____ WAIVE _____ a spot test prior to application and I agree to release Debra Rasberry, assistants and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments.

_______I have been told that allergic reactions to pigment are very rare, however, they can and do occur and when they occur they can be serious and especially difficult and very troublesome to treat.

_______I have been told that this procedure will involve pain and discomfort.

_______I understand the markings are permanent and that there is a possibility of hyper pigmentation resulting from a procedure, especially in individuals prone to hyper pigmentation from a scar or other injury.

_______I have been told that a follow up procedure may be required.

_______I have been told that there is a chance that I may experience a corneal abrasion.

_______Other risks involved with the procedure may include, but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction(s) to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.

_______I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me.

_______I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.

_______I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify Debra Rasberry and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and Debra Rasberry or the breach thereof, shall be settled by arbitration in the state of Louisiana in accordance with the Rules of the American Arbitration Association and judgment of the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

_______I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Debra Rasberry, a health care practitioner, Louisiana Department of Health and Hospitals.

_______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.

Signature ______________ Date ___________