11550 Jonesbridge Rd, Suite# 6, Alpharetta GA 30022
Email: firstname.lastname@example.org Tel: (678) 829-7722
MICROBLADING Consent Form
Description of Design and Color
Do you have or have you ever had any of the following conditions (Yes or No):
I, have been fully informed of the inherent risks associated with getting a tattoo. Therefore, I fully
understand that these risks, known and unknown, can lead to injury including but not limited to: allergy, infection, scarring, difficulties in the detection
of melanoma and allergic reactions to tattoo pigment, latex gloves and/or soap. Having been informed of the potential risks associated with getting a tattoo I
wish to proceed with the tattoo procedure and application and freely accept and expressly assume any and all risks that may arise from tattooing.
I, have received, read and understood aftercare procedure of microblading.
I, not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Tattoo
Studio without duress or coercion.
Artist makes no attempt, or claim to practice medicine. Some individuals will have complications related to microblading application. They are usually
mild and last only a few days, however extreme complications are a possibility, if you are healthy and there is no visible reasons restricting you from
receiving a tattoo you must approve of the design and color before the application of your microblading.
“Gwinnett County Board of Health makes no guarantee there will be no injury due to aforementioned procedure being performed. Furthermore,
Gwinnett County Board of Health assumes no liability for any injury which may occur.”
THE UNDERSIGNED acknowledges that artist has explained the nature of all the above –noted treatment of microblading including the risks and dangers inherent therein.
I HEREBY CONSENT to performing the above-noted treatment procedures on me and in consideration of their so doing; I hereby release and forever
discharge Cosmo Med Spa & Salon, from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment
procedures, which I, my heirs, executors, administrators or assigns can, shall, or may have. (NO REFUND ON ANY TREATMENT).