NAME:
DATE:
DOB:
PHONE:
ADDRESS:
EMAIL:
_______ It has been explained to me that the procedure to be used is referred to as Micro-Pigmentation (the process of implanting
micro-deposits of pigment into the epidermal layer of the skin). Micro-Pigment Implantation is a form of tattooing used for the
purpose of permanent cosmetic makeup and skin imperfection camouflage or tattoo removal.
_______ I realize the procedure will probably result in permanent and irreversible color change in the skin area treated. However
rare, some of possible complications resulting from this procedure may include infection, scarring, swelling, bruising, numbness,
and post procedure discomfort, allergic reaction to one of the pigments or anesthetic agents (topical or oral).
_______ I understand that the practice of this procedure is NOT an exact science. Colors may not match perfectly or appear
exactly as expected. Over the months and years following the procedure, softening, fading or change of color of the pigment may
occur.
_______ I understand that there is a possibility of hyperpigmentation resulting from a procedure.
_______ I have been told that this procedure will most likely involve some pain and discomfort.
_______ I understand that no warranty or guarantees have been made to me as to the result of this procedure.
_______ I understand that there will be before and after pictures taken. Pictures may be used for website.
_______ I have been given the opportunity to ask questions about the procedure and the risks involved.
_______ Full amount is due at beginning of service. You may pay by cash, check or credit card. No refunds, no exceptions.
_______ I understand that the description of the procedure is not meant to scare or alarm me. It describes the procedure to be
utilized so I may make an informed decision to proceed or refuse the procedure.
In consideration of having a service provided by Dejana Alijevic/Dual Beauty LLC, I
______________________________________________, fully release and discharge Dejana Alijevic and all of her employees, agents,
servants, representatives, and associated corporations (hereafter referred to as Dejana Alijevic/Dual Beauty LLC) without
limitation, from any and all claims, losses, demands, rights of causes of action, damages or injuries to my person or property,
present or future, whether known, anticipated or unanticipated, that may occur from any cause whatsoever, whether based on tort,
contract, products liability, or other theory of recovery, as a result of or arising out of any treatment or surgery that may arise
from any treatment or procedure by Dejana Alijevic, including , but no limited to, any claims for known, unknown, latent,
developed, or undeveloped injuries; anticipated and unanticipated consequences, and known and unknown developments of any
such injuries and claims with respect to the nature, extent, and permanency of any such injuries.
SIGNATURE: _________________________________________________________
DATE: _____________________________