Don't forget to bring government issued photo ID with you to your appointment, its required!
Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people
Lucky’s Tattoo and Piercing have put in place preventative measures to reduce the spread of COVID-19; however, Lucky’s Tattoo and Piercing cannot guarantee that you will not become infected with COVID-19. Further, getting a tattoo or piercing could increase your risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering Lucky’s Tattoo and Piercing and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Lucky’s Tattoo and Piercing employees.
I voluntarily agree to assume all of the possible risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury. disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Lucky’s Tattoo and Piercing.
I hereby release, discharge, and hold harmless Lucky’s Tattoo and Piercing LLC, its employees, agents, of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Lucky’s Tattoo and Piercing employees, agents, whether a COVID-19 infection occurs before, during, or after participation in any tattoo, piercing work, or any other services provided by Lucky’s Tattoo and Piercing LLC.
CLIENT HEALTH QUESTIONNAIRE
PRIOR TO THE START OF MY SERVICE, I CONFIRM THAT:
I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks.
I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks.
I have not traveled outside of my immediate daily routine for the past two weeks.
I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell.
If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Lucky's Tattoo and Piercing as soon as possible.
I will follow all posted studio rules to keep myself, studio staff, and those around me safe.
Possible Risks, Hazards, or Complications
Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others.
Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See the aftercare sheet for instruction on care.
Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven Appearance.
Asymmetry: Every effort will be made to avoid asymmetry, but our faces are not symmetrical so adjustments may be needed during the follow-up session to correct any unevenness.
Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now.
MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low-level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI Technician of any tattoos or permanent Cosmetics.
The alternative to these possibilities is to use traditional cosmetics and NOT undergo the Semi-Permanent Eyebrow procedure.
Consent and release for procedures performed:
Statement of Consent and Recitals
Aftercare instructions have been explained to me and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email the practitioner, Alicia Dane.
I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness, and bruising may occur.
I 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 tanning beds, pools, some skincare products, and medications can affect my permanent makeup.
I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue.
I will tell all skincare professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.
I accept the responsibility to explain to you the desire for specific colors, shapes, and positions for any procedure done today.
I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 60 days.
I acknowledge that the proposed procedures(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as infection, misplaced pigment, poor color retention, and hyper-pigmentation.
I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Touch-ups must be completed within 60 days of initial procedure.
I have been quoted the cost of today’s appointment which includes the touch-up. Touch- ups must be completed within 60 days of the initial procedure to be considered included.
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s). 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 Alicia Dane, as my Eyebrow Microblading technician to perform on my body the 3D Eyebrow Microblading procedure desired today.
Today's Date: May 26, 2022