Consent Form * First Name Last Name Email * Phone * (###) ### #### PLEASE INITIAL THE FOLLOWING: * I certify that I am over the age of 18, and that I have a U.S government issued ID to prove so. I am not under the influence of any drugs or alcohol. 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 at this time. I acknowledge that obtaining permanent make-up or tattoo is my choice alone. The application of permanent make-up or tattoo procedure will result in a permanent change to my appearance, and that needles and inks will go into my skin. No representations have been made to me as to the ability to later restore the skin involved to the original condition, and it is very costly to remove. I certify that the following statements are all true: I am not pregnant or breastfeeding I do not have epilepsy I do not have cardiac valve disease or suffer from any heart conditions or take medications that thins my blood I have not used Accutane or prescription acne treatment within the last year I have not had laser tattoo removal within the last 4 weeks I have not gotten botox or filler within the last 4 weeks of the procedural site I have informed the Technician if I suffer from hepatitis or any other bloodborne pathogen exposure or any other communicable disease I do not suffer from any medical or skin condition(s) such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the permanent make-up/tattoo, or any open wounds or lesions at the site of the tattoo. I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures. I have advised the Technician of any allergies to latex gloves, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have an allergic reaction to the permanent make-up/tattoo process and further acknowledge that such reaction is possible. I am aware that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. I acknowledge that infection, although rare, is always possible as a result of permanent makeup/tattoo application, and I agree to follow all suggested instructions concerning the care of the permanent make-up/tattoo site while it is healing. I understand the risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infections, poor color retention and hyperpigmentation. I understand I will have tattoo/permanent make-up applied using appropriate instruments and sterilization techniques. I understand that the permanent make-up site usually takes 4 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors, and the management of the tattoo studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility for the decision(s) made consenting to this permanent procedure. I acknowledge that the Technician has the right to refuse service to any client who he/she deems unfit for the procedure. I authorize the technician as my permanent cosmetic technician to perform on my body. I am informed of my technician’s qualifications and licenses. I acknowledge and consent to Orion Ink Studio to use images of my tattoo(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed, and/or television etc. I consent to allowing photos and videos taken of me before, during, and after the procedure. Check all that apply: Serious health conditions Bloodborne Pathogen diseases such as HIV, AIDS, Hepatitis Diabetic (If yes, is it controlled?) Autoimmune disorder Allergies Currently taking blood thinning drugs If yes to any above, please list: * I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent make-up from Lalita Sunthonpataruk hereafter called “Technician” and that all of my questions have been answered to my full and total satisfaction. I acknowledge that I have been advised of the matters set forth below and agree as follows. Date MM DD YYYY Thank you, your consent form has been submitted.