CONSENT FOR SCALP MICROPIGMENTATION, PERMANENT MAKE-UP APPLICATION, RELEASE, AND WAIVER OF ALL CLAIMS
I, the undersigned (the “Recipient”), acknowledge by signing this consent for scalp micropigmentation, permanent make-up application, release, and waiver of all claims (the “Agreement”) that I have been given the full opportunity to ask any and all questions I may have about obtaining scalp micropigmentation, a form of permanent make-up from a Joe Barghi or a trained Full Micro Master Artist/Apprentice (the “Technician”) and that all of my questions have been answered to my full and total satisfaction.
DESCRIPTION OF SCALP MICROPIGMENTATION TREATMENT
Technician, on behalf of Full Micropigmentation LLC, a Nevada limited-liability company (“FM”), shall use FM’s proprietary technique for applying pigment to the scalp. Recipient understands and acknowledges that FM’s techniques and the scalp micropigmentation treatment is analogous to receiving a tattoo. When receiving the scalp micropigmentation treatment from FM and its Technician, Recipient shall have pigments inserted into, or just below, the scalp’s epidermis using needles and other puncturing or insertion devices. Depending on any particular Recipient’s needs, more than one session or course of scalp micropigmentation treatments may be needed to achieve Recipient’s desired result. As set out in this document, some irritation after receiving a scalp micropigmentation treatment is usual. Recipient should consult his or her physician before receiving any scalp micropigmentation treatment from FM or Technician. Recipient further understands and agrees that FM’s scalp micropigmentation treatment is performed over the course of three sessions. FM wishes for each of its customers to achieve the results they desire, and for this reason, FM will provide Recipient with one additional complimentary scalp micropigmentation session upon Recipient identifying areas requiring further attention and micropigmentation treatment, which must be redeemed within one year of Recipient’s third and final session.
As a condition of receiving scalp micropigmentation treatment from FM and the Technician, I, by initialing each paragraph below, represent that I have carefully reviewed each of the following paragraphs, had the opportunity to consult with an independent physician, and further have asked FM and the Technician any further or other questions I may have about the scalp micropigmentation treatment and the following acknowledgements, have had each and every one of those questions answered to my satisfaction, and therefore expressly agree to accept each and every risk set forth below, without limitation:
I acknowledge that obtaining scalp micropigmentation treatment from FM and the Technician, which is a form of permanent make-up, is my choice alone, and I am executing this document while over 18 years of age, of sound mind, and not under the influence of any alcohol or other drugs.
I acknowledge that FM and the Technician’s micropigmentation treatment is the application of ink to the scalp, may—and likely will—result in a permanent change to my appearance, and that needles and inks will go into my scalp in order to be permanently left there for coloration purposes. Neither FM nor the Technician have made any representations to me as about the ability to later restore the skin involved in permanent make-up to the original condition and it could be costly to remove, and I understand that removal of the micropigmentation treatment would be unlikely, costly, and potentially uncomfortable or painful.
I am not pregnant or nursing, and I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or any other bleeding disorder. I do not have cardiac valve disease or suffer from any heart conditions or take medication that thins my blood. I acknowledge that accurately and honestly confirming the absence of these conditions is important to FM and the Technician safely performing the micropigmentation treatment upon me.
If I suffer from hepatitis, jaundice, or other risk factors for blood born pathogen exposure, or any other communicable disease, I have informed the Technician of the fact and have been advised of any medications and procedures necessary to promote the satisfactory healing of my micropigmentation procedure, and set forth those medications or diseases in writing in the lines provided below, if applicable (if none, write “none”):
I do not suffer from any medical or skin conditions including, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of permanent make-up, or any open wounds or lesions at the site of the scalp micropigmentation treatment.
I do not have a history of medication use that would have any negative interaction that I know of with the scalp micropigmentation treatment, nor am I currently using medication, including prescription antibiotics used prior to dental or surgical procedures.
I have advised the Technician of any allergies to latex gloves, soaps, medications, cosmetics, topical applications, or other substances, whether artificial or natural. I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reactions to the permanent make-up process and further acknowledge that such reaction is possible even after I have informed the Technician and FM of all possible known allergens.
I acknowledge infection is always possible as a result of scalp micropigmentation, a form of permanent make-up application, and I agree to fully follow all suggested instructions concerning the care of the procedure site while it is healing.
I understand I will have permanent scalp micropigmentation applied by FM and Technician using appropriate instruments and sterilization techniques. I understand that the scalp micropigmentation site usually takes 2 weeks or longer to heal.
I acknowledge that scalp micropigmentation and the scalp micropigmentation treatment can cause pain, discomfort, and irritation of the scalp. I further acknowledge and understand that I may seek, desire, or need medical treatment following administration of my scalp micropigmentation treatment by FM and the Technician, and that I may be dissatisfied with the coloring, appearance, presentation, shape, or other aspect of the scalp micropigmentation treatment I receive from FM and the Technician, and agree to release and waive any claims against FM and Technician for the same. In consideration of these concerns, and in addition to the waiver provided below, I agree to release and forever discharge, and hold harmless, the Technician, all employees, contractors, owners, and the management of this business from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my procedure, and conduct used in my tattoo. I assume all responsibility for the decisions made consenting to this permanent procedure.
I understand and acknowledge that FM instructs and advises all of its clients to shave their heads using a zero-guard/razor in order to achieve optimal results from micropigmentation treatment. I further understand the necessity for such a close shave is to ensure an even and consistent deposit of pigment, which I desire to receive to mimic hair follicles. I have been advised, understand, and accept the risk that if I fail to follow FM’s advice regarding the use of a zero-guard/razor on my hair, the application of micropigmentation may appear uneven or spotty, and not yield the results I desire or expect. I further acknowledge that when the micropigmentation ink is deposited in between long hairs that have not been shaven down with a zero-guard/razor as instructed and advised by FM, there is a risk of using too much ink, which can appear unnatural or may darken to an unwanted color. I accept all of the foregoing risks arising from my compliance, or lack thereof, with FM’s instructions regarding the level to which my head should be shaven to receive optimal results from FM’s micropigmentation treatment.
I understand and acknowledge that this risk is also present when FM deposits pigments over scars. I understand that the pigmentation FM deposits over scarring may not be as dark as I prefer because if FM deposits pigmentation using too much pigment, or too dark of pigment, the scarring may become more prominent the scar itself may appear as a dark line across my scalp. I understand that scar tissue is a different consistency than regular skin, and this can cause the scar to react differently to the ink/treatment as compared to the areas with regular skin. Furthermore, this scar treatment will help camouflage the scar quite a bit, but it will not completely get rid of the scar, as FM’s micropigmentation procedure(s) will not remove any form of scarring. I accept all of the foregoing risks regarding the amount, level, shade, and darkness of pigmentation FM is to apply to any pre-existing scarring that may be present on or around my scalp.
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, and have had the opportunity to consult with an independent physician, doctor, or other medical professional of my choosing to discuss these risks prior to undergoing scalp micropigmentation treatment. These potential risks, as identified by the Federal Food and Drug Administration, include the formation of granulomas, keloids, and potential interference with certain imaging scans, including magnetic resonance imaging. I accept any and all risks associated with FM and the Technician’s scalp micropigmentation treatment with full recognition of these risks.
I acknowledge, release, and expressly grant consent for Technician and FM to use my image, name, likeness, and voice in perpetuity and to the fullest possible extent of the law for FM’s promotional, marketing, advertising, informational, and other material in printed, visual, audiovisual, audio, and other formats in printed material such as advertisements in newspapers, periodicals, billboards, on television, on the radio, or on the Internet whether in visual, audiovisual, or audio form whether as online advertisements, social media websites, video websites, e-mail solicitations, and any other manner that FM or Technician deem appropriate anywhere in the world. I grant these rights to FM and Technician on a non-exclusive basis, and authorize FM and Technician to license all rights under this section as necessary to achieve the purposes set forth herein. I understand that FM and/or the Technician may edit, distort, over-dub, and otherwise alter my name, likeness, voice, and other attributes of the rights granted to them under this section, and authorize them to do so for the purposes provided herein. My acknowledgement of this section does not in any way obligate FM or the Technician to use any of the rights granted under this section for any purpose.
I acknowledge that full payment is due in full before the start of my procedure. Any issues regarding dishonored checks, credit card chargebacks, or other payment disputes will be my full and complete responsibility.
I acknowledge my receipt of FM’s Pre-Care and Post-Care Instructions (collectively, the “Instructions”), which accompany this Consent Form. I understand that I must follow all of FM’s Instructions in order to achieve optimal results from FM’s micropigmentation procedures. I understand, agree, and acknowledge, that my failure to follow the Instructions could result in an unexpected, diminished, warped, undesirable, or otherwise unsatisfactory final result. I understand, agree, and acknowledge FM’s warning that I should not consume alcohol prior or subsequent to receiving any micropigmentation procedure from FM, as alcohol may impair the micropigmentation process or interfere, distort, or otherwise adversely affect the final result of any micropigmantation procedure FM administers to me. I further understand, acknowledge, agree, and accept the risk of disregarding FM’s warning that for the first three to four days following scalp micropigmentation treatment (the total amount of which may vary among individuals), I may not sweat on the affected area, wash the affected area, or expose the area to sunlight.
RECIPIENT WAIVER AND RELEASE
Recipient, having read, understood, and initialed each and everyone one of the preceding acknowledgements (collectively, the “Acknowledgements,” and individually an “Acknowledgement”), understands and agrees that it waives, shall waive, forever release, and agree to never pursue any and all claims arising from any Acknowledgement as it relates to the scalp micropigmentation treatment FM and Technician apply to Recipient. Recipient releases FM and Technician, and their respective employees, officers, directors, partners, shareholders, agents, attorneys, representatives, affiliates, related companies, and successors from any and all liabilities, claims, demands, damages (including general, special, exemplary or punitive damages, or consequential damages of any kind), obligations, debts, costs, actions, and causes of action, whether for intentional or negligent conduct, or in tort or contract, arising from FM or Technician’s provision of the scalp micropigmentation treatment to Recipient, any Acknowledgement and collectively all Acknowledgements within this Agreement, or any other action, conduct, treatment, or relationship arising from or related to this Agreement.
If any term, clause, or provision hereof is held invalid or unenforceable by a court of competent jurisdiction, such invalidity shall not affect the validity or operation of any other term, clause, or provision and such invalid term, clause, or provision shall be deemed to be severed from the Agreement. No amendment, alteration, modification or variation of this Agreement shall be valid or binding unless set forth in a further written agreement executed by both of the parties hereto. Recipient, as well as FM and Technician, have had an opportunity to review and revise the language of this Agreement, and therefore the language of this Agreement shall therefore not be presumptively construed either in favor of or against any party hereto. The parties hereto acknowledge and agree that this Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof; that no promise or other inducement has been made except as expressly set forth herein; that this Agreement supersedes any other communications and understandings with respect to the subject matter hereof; and that no representations or agreements, oral or otherwise, among the parties hereto not included herein are of any force and effect.
This Agreement shall be construed under, governed and enforced in all respects, including interpretation, by the substantive laws of the State of Nevada without regard to Nevada’s choice-of-law rules. In the event either Party seeks to enforce this Agreement or assert a claim for breach, the Parties hereby consent to the exclusive jurisdiction of federal and state courts sitting in Clark County, Nevada to enforce the terms of this Agreement and to remedy any violation thereof, and the Parties consent to personal jurisdiction in, and venue of, such courts, expressly waiving any objection based on personal jurisdiction grounds or the doctrine of forum non conveniens. In any action arising from or related to this Agreement, the parties hereto agree to bear their own attorneys’ fees and costs.
IN WITNESS WHEREOF, FM and the Recipient have executed this document by their signatures affixed, as of the dates stated, below.
Today's Date: October 16, 2019