CONSENT TO TATTOO PROCEDURE
RELEASE AND WAIVER OF ALL CLAIMS
1. I acknowledge by signing this release that I have been given full opportunity to ask any and all questions that I might have about obtaining a tattoo and that all my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and I agree as follows:
2. If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition or I take medication that thins the blood, I have advised my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs.
3. I do not have medical skin conditions such as, but not limited to acne, scarring (keloid), eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with the application and/or results my tattoo.
4. I acknowledge it is not reasonably possible for Pretty Please Studio to determine if I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible.
5. I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and can go to the Pretty Please Studio website for aftercare instructions. I agree to care for my tattoo to the best of my ability.
6. I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin is dark, the colors will not appear as bright as they do on light skin. I understand that a tattoo is a work of art and minor imperfections are likely.
7. 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.
8. I acknowledge that a tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo.
9. I have truthfully represented to Pretty Please Studio that I am at least 18 years of age and that obtaining a tattoo is by my choice alone.
10. I have been told that the procedure/s may be called Micropigment implantation, cosmetic tattooing, or permanent makeup; it is the process of implanting micro insertions of pigment into the dermal layer of skin. This is a form of tattooing; I voluntarily allow Pretty Please Studio as my cosmetic technician, to perform the following procedure/s:
11. I agree to WAIVE a spot test prior to application, if I receive a spot test, I must wait 24 to 48 hours before procedure/s can be done.
12. I understand spot testing may identify individuals who develop an immediate reaction to pigment, however, spot testing does not identify individuals who may have a delayed allergic reaction to pigment.
13. I have been told that allergic reaction to pigments are very rare but may occur.
14. I have been told that this procedure/s may involve pain and discomfort for some people.
15. I understand the markings are permanent and that there is a possibility of hyper pigmentation resulting from procedure/s, especially in individuals prone to hyper pigmentations from scars, or other injury.
16. I have been told that a follow up procedure may be required.
17. I have been told that there is a chance that I may experience a corneal abrasion during the upper or lower eyeliner procedure.
18. I understand that if I have an infection, adverse reaction, allergic reaction or a complaint of any kind to the procedure/s, I must notify Pretty Please Studio/Sheryle Colombo, a health care practitioner and the Wisconsin Department of Health Services.
19. I further agree that any controversy, or claim arising out of, or relating to this consent and/or any signed contract between myself and Pretty Please Studio/Sheryle Colombo or the breach thereof, shall be settled by arbitration in the state of Wisconsin, in accordance with the Rule of the American Arbitration Association and judgment of the award rendered by the arbitrator/s may be entered in any court having jurisdiction thereof.
20. 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 unknown reason associated with the procedure planned for me.
21. I have been given an opportunity to ask questions about the procedure/s, and the products to be used and the risks and hazards involved, and I believe that I have sufficient information to give this informed consent.
PLEASE READ AND INITIAL:
___ _ I acknowledge that it is not possible for my technician to determine whether I might have an allergic reaction to the dyes, pigments or process used to do the tattoo. In addition, I agree to accept the risk that such a reaction is possible.
___ I acknowledge that infection is always possible, particularly in the event that I do not take care of my tattoo and that if I see signs of infection that I will see a physician.
___ I acknowledge the receipt of written after care instructions advising me of the proper care of my tattoo. In addition, I recognize the absolute necessity for following these instructions.
____ I acknowledge that a tattoo is considered permanent, that it can only be removed by a surgical procedure, that any removal may leave permanent scarring and disfigurement.
____ I acknowledge that 1 am not under the influence of drugs or alcohol, or any intoxicating substance at the time of the procedure.
I agree to release and forever discharge and hold harmless Pretty Please Studio, and all employees from any and all claims, damages or legal actions arising from or connected in any way to my tattoo or the procedure and conduct used in the application of my tattoo. 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 duly informed and therefore I request the application of a tattoo by Pretty Please Studio:
Covid-19 Release Form
COVID -19 Health Inquiry and Liability Release Form
I understand the virus has a long incubation period and that carriers of the virus may be asymptomatic i.e. without symptoms. It is impossible to determine who has the virus and who does not at this time.
Symptoms of COVID-19 include:
Loss of sense of taste or smell
Shortness of breathe
I confirm that I am not presenting with any of the above symptoms ________Initial
I confirm that in the past 14 days I have not experienced a fever (greater than 100.4 F) OR symptoms of lower respiratory illness such as a cough, shortness of breath, difficulty breathing or sore throat? ________Initial
I confirm that in the past 14 days I have not come into close contact (within 6 ft) of someone who has a laboratory-confirmed COVID-19 diagnosis or is in the process of being tested or evaluated for COVID-19?
I confirm that in the past 14 days I have not come into close contact (within 6 ft) of someone who had a fever (greater than 100.4 F) OR symptoms ________Initial
I confirm that I am not living or caring for someone with COVID-19 ________Initial
I confirm that I, as well as all household members have not been diagnosed with COVID -19 ________Initial
I confirm that I have not traveled outside the country, or to any city outside of our own that is or has been considered a “hot spot” within the last 45 days _______Initial
I understand that this business and this practitioner cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form, changing health and safety recommendations by local, State or Federal authorities or the health history provided by each client. ________ Initial
By signing below I agree to each above statement and release the practitioner and business from any and all liability for the unintentional exposure or harm caused by COVID -19. Your practitioner and all practitioners in this facility agree that they abide by these same standards and affirm the same. We also affirm that we have taken the highest standard precautions in compliance with OSHA, local, State and Federal guidelines for sanitation protocols to more thoroughly fight the spread of COVID -19 and other communicable conditions or diseases.
Permanent Makeup Application
I thank you for choosing Pretty Please Studio and the trust that you will be placing in me. There are a few things to keep in mind as you move forward with this decision to have permanent makeup.
First and foremost, it is imperative to understand that it is a two session process and takes a minimum of 8 weeks for completion. Very rarely can it be completed in one session and on occasion, it may take three.
Unfortunately, social media images, advertising and celebrity artists can give a false perception that permanent makeup is a quick, easy and seamless process. This is almost never the case and each person’s experience will vary.
My goal for the first session is to get an adequate amount of ink into the skin. There is some pigment loss and/or retention factors due to skin type, age of skin, pain sensitivity of client and proper care. The implantation of ink into the skin will undergo the natural healing process of sloughing, renewing and color clarification which takes 4-6 weeks to complete. At this point your tattoo has now attained 50% completion.
During the second session I focus on shape, symmetry and color modification. This is where additional work due to asymmetry or areas of uneven pigmentation will be addressed. I make the appropriate modifications as needed. Then, an additional 4 weeks of healing will take place. At this point we are able to safely judge the outcome of the results.
At Pretty Please Studio, my aim is to give you what you are desiring. This will take time and patience from the both of us. I ask that you refer back this form for reassurance or if you must, feel free to contact me.
Remember it is my work displayed on your face and I want the best possible outcome just as you do. We are on this journey together and I am excited as well as grateful to be a part of this with you.