COSMETIC TATTOO DISCLOSURE & RELEASE AGREEMENT

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a cosmetic tattoo. I have reviewed the FAQ & Policies sections on www.syarbrows.com prior to my appointment, and I understand the info there, and have had any further questions answered to my full satisfaction. I also have read and I specifically, acknowledge I have been advised of the facts and matters set forth below and I agree as follows:

If I have any condition that might affect the healing of this tattoo, I will advise my tattooer. I am not pregnant or nursing. I am not under the influence of alcohol or drugs.

I understand that I must inform my tattoo artist of any and all medication(s) I am currently taking. (Pain control medications such as aspirin or ibuprofen may cause the blood to thin, and excessive bleeding may occur during or after the procedure). I do not currently take Accutane and/or have not taken for at least 12 months.

I do not have medical or 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 tattoo. If I have any type of infection or rash anywhere on my body, I will advise my tattooer.

I acknowledge no warranty has been made to me as a result of this semi permanent makeup, or correction procedure, and that the final result cannot be guaranteed. Cosmetic tattooing is considered semi-permanent, and will fade with time. It is not reasonably possible for the representatives and employees of this clinic to determine whether I might have bleeding, swelling, or an allergic reaction to the pigments (pigments contain: Sterile Water, Glycerin, Isopropyl Alcohol, Iron Oxides, Titanium Dioxide, Chromium Oxide) or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. I realize that there is potential for discomfort during the procedure and during the healing process.

I have been informed that possible complications or side effects from tattoos may include: abscesses, allergies, excessive bleeding, heavy metal poisoning, infection, keloid formation, muscle paralysis, nerve paralysis, scarring, blood borne pathogens, tongue swelling, throat closure and tooth fracture. Misplacement or migration of the pigment can occur, under rare circumstances, requiring excision and/or correction of the misplaced pigment. A tattoo can only be removed with surgical or laser procedures, and that any effective removal may leave permanent scarring or disfigurement.

I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received verbal and physical aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense. Touch ups on ‘cover up' tattoos will also be done at my own expense do to the nature of covering others previous work. I understand that signs of infection include fever, swelling and redness. l have been instructed to contact a medical provider if signs of infection or complications occur. If I do not have a local provider I can call Riverstone Health at 406· 247· 3200 for assistance.

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 color is dark, the colors will not appear as bright as they do on light skin. 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 that a tattoo is a very 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 a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.

I acknowledge I am over the age of eighteen and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I have reviewed and approve my tattoo design and I accept full responsibility for their accuracy. I release the studio and its representatives and subsidiaries of all claims for injury, seen or unseen, that may occur as a result of this procedure.

I hereby give my artist and/or Natural By Nature permission to copyright or publish and/or use photographs of me to be shown on social media (Instagram/Facebook/etc.) or advertising, or any lawful purpose whatsoever. I waive any right I may have to inspect and/or approve the finished product or use of to which it may be applied. (Your face will not be shown and you will not be tagged in the photo. Just a before and after photo of the work that was done.)

DO YOU HAVE OR HAVE YOU PREVIOUSLY HAD ANY OF THE FOLLOWING:

Please circle 'Yes’ or ‘No’

YES NO History of MRSA

YES NO Botox, Last Treatment Date:

YES NO Diabetes, Type:

YES NO Hepatitis: A B C D

YES NO Forehead/Brow Lift

YES NO Easy Bleeding

YES NO Alcoholism

YES NO Recreational Drugs, Please List:

YES NO Smoker

YES NO Heart Condition

YES NO Chemical Peel, Last Treatment:

YES NO Facial Laser Treatment, Last Treatment:

YES NO Pregnant or Breastfeeding Now

YES NO Brow or Lash Serums

Any Additional information you feel is important to your treatment(s)?

CONTRAINDICATIONS:

*Epilepsy *Diabetic *Chemotherapy *Sick: (cold, flu, etc) *Pregnant or Nursing *Major Heart Problems *Psoriasis, Rash or Sunburn on or Around Treated area *An Allergy to Lidocaine, Tetracaine or Epinephrine *Botox in the Past Month *Accutane in the past year *Previous Permanent Makeup *Viral Infections/ Disease *Lash/Brow Growth Serums

Please Read and Initial Each Line:

                 Aftercare instructions have been explained and a written copy has been given to me, which I will follow to the best of my ability. I will call or email if l have questions.

                  I understand that a certain amount of discomfort is associated with this procedure, and that swelling,redness and bruising may occur.

                   I understand that topical anesthetics are used to numb the area being treated. Lidocaine. Benzocaine, Tetracaine and Epinephrine are amongst the anesthetics used. If you are allergic to any of these topical anesthetics please inform me prior to your appointment.

                   l understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas.They will alter the color and cause premature exfoliation of the pigment.

                  I understand that successful color saturation cannot be guaranteed due to hidden scar tissue, and that uneven pigment can result from poor healing, infection, bleeding or a number of other outside causes. Your follow-up will most likely correct an uneven appearance.

                  l understand that every effort will be made to avoid asymmetry, but that our faces are not symmetrical so adjustments may be needed during the follow-up session to correct any unevenness.

                  l understand that implanted pigment color can change or fade over time due to circumstances beyond your control and that I will need to maintain the color with future touch-up sessions.

                  I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to enhance any areas which may have had poor color retention. Touch-ups MUST be completed within 6-10 weeks of initial procedure. 

                  I have been quoted the cost of my appointment, and that my touch-up session MUST be completed within 6-10 weeks of initial procedure. Additional touch-up sessions cost a minimum of $150, and are subject to change at any time.

I certify that I have read or have had read to me the consent of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize my technician,  Shelby Yarbrough to perform my procedure today.