is obligated to perform procedures in strict compliance with all hygiene and health protection measures. This information is confidential, and it shall also be handled in that way. LUXURY BEAUTY STUDIO assumes no liability in case of giving false information.

CONTRACTUAL OBLIGATIONS

I am___________________________ over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure_______(initial). The general nature of cosmetic tattooing as well as the specific procedure to be perform has been explain to me _________(initial)

If I suffer from hepatitis or other risk factors from Bloodborne Pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advise of any medications and procedure necessary to promote the satisfactory healing of my permanent make-up tattoo _______(initial).

I acknowledge that obtaining this indicated permanent cosmetic procedure is my choice alone______ (initial). The application of permanent make-up will result in a permanent change to my appearance, and that needles and pigment will go into my skin______ (initial). No representations have been made to me as the ability to later restore the skin involved in permanent-makeup to the original condition, and it is very costly to remove________ (initial). The pigment is absorbed differently due to differences in the skin quality, thus there is no warranty for the treatment success________ (initial).

I acknowledge that tattoo ink, pigments have not been approved by the FDA and that the health consequence of using these products are unknown. You might take a 5-7 day patch test to determine this. Please inital to : Waive__________(initial) or Take a patch