CONSENT FOR STRETCH MARK & SCAR CAMOUFLAGE, PERMANENT MAKE-UP APPLICATION, RELEASE, AND WAIVER OF ALL CLAIMS
I, the undersigned (the “Recipient”), acknowledge by signing this consent for Stretch Mark & Scar Camouflage, 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 my camouflage tattoo, a form of permanent make-up from a Joe Barghi or a Full Micropigmentation Certified Artist (the “Technician”) and that all of my questions have been answered to my full and total satisfaction.
DESCRIPTION OF STRETCH MARK & SCAR CAMOUFLAGE 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 body. Recipient understands and acknowledges that FM’s techniques and the Stretch Mark & Scar Camouflage treatment is analogous to receiving a tattoo. When receiving the Stretch Mark & Scar Camouflage treatment from FM and its Technician, Recipient shall have pigments inserted into, or just below, the body’s epidermis and dermis using needles and other puncturing or insertion devices. Depending on any particular Recipient’s needs, more than one session or course of Stretch Mark & Scar Camouflage treatments may be needed to achieve Recipient’s desired result. As set out in this document, some irritation after receiving a Stretch Mark & Scar Camouflage treatment is usual. Recipient should consult his or her physician before receiving any Stretch Mark & Scar Camouflage treatment from FM or Technician. Recipient further understands and agrees that FM’s Stretch Mark & Scar Camouflage treatment is performed over the course of one or two 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 Stretch Mark & Scar Camouflage session upon Recipient identifying areas requiring further attention and treatment, which must be redeemed within one year of Recipient’s final session.
As a condition of receiving Stretch Mark & Scar Camouflage 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 Stretch Mark & Scar Camouflage 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 Stretch Mark & Scar Camouflage 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 Stretch Mark & Scar Camouflage treatment is the application of ink into the body, may—and likely will—result in a permanent change to my appearance, and that needles and inks will go into my body in order to be permanently left there for coloration and camouflage purposes. Neither FM nor the Technician have made any representations to me 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 Stretch Mark & Scar Camouflage would be unlikely, costly, and potentially uncomfortable or painful.
I acknowledge that my stretch marks or scars are over 2 years old and I accept responsibility for the determining area, color, and position of the Stretch Mark & Scar Camouflage tattoo. I acknowledge that the color selection and color results of this treatment are not an exact science, and that sun exposure, skin type, body chemistry, age, and other health factors may effect final results over time.
I acknowledge that many laser treatments including those for tattoo removal, anti-aging, removal of lines; may or will effect the pigment of my Stretch Mark & Scar Camouflage tattoo because of the titanium dioxide in the pigment. I agree to further inform future technicians or any operating such devices and services, that I have a cosmetic tattoo with titanium dioxide.
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 Stretch Mark & Scar Camouflage 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 Stretch Mark & Scar Camouflage 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 Stretch Mark & Scar Camouflage treatment.
I do not have a history of medication use that would have any negative interaction that I know of with the Stretch Mark & Scar Camouflage 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 Stretch Mark & Scar Camouflage, a form of permanent make-up application, and I agree to fully follow all suggested instructions concerning the pre-care and post-care guidelines of the procedure site while it is healing.
I understand I will have a permanent Stretch Mark & Scar Camouflage tattoo applied by FM and Technician using appropriate instruments and sterilization techniques. I understand that the Stretch Mark & Scar Camouflage site usually takes 2-3 months or longer to heal. I understand and accept the risk of hyper-pigmentation or hypo-pigmentation; the darkening or lightening of color which will lengthen heal time. I acknowledge that there may be excessive swelling, redness, or bruising.
I acknowledge that the Stretch Mark & Scar Camouflage treatment can cause pain, discomfort, and irritation of the treated body area during and after the procedure. I further acknowledge and understand that infection is unusual, but I may seek, desire, or need medical treatment following administration of my Stretch Mark & Scar Camouflage treatment by FM and the Technician. I further acknowledge that I may be dissatisfied with the coloring, appearance, presentation, shape, or other aspect of the Stretch Mark & Scar Camouflage 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, licensees, 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 cosmetic 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 follow pre-care and post-care guidelines in order to achieve optimal results from the Stretch Mark & Scar Camouflage treatment. I further understand the necessity for such detailed regimen is to ensure an even and consistent deposit of pigment, which I desire to receive in order to camouflage my stretch marks & scars. I have been advised, understand, and accept the risk that if I fail to follow FM’s advice regarding the pre-care and post-care guidelines, the application of Stretch Mark & Scar Camouflage tattoo may appear uneven or spotty, and not yield the results I desire or expect. I further acknowledge that when the Stretch Mark & Scar Camouflage ink is deposited on tanned, burned, or unhealthy skin, as instructed and advised by FM, there is a risk of using too much ink or hyperpigmentation, 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 pre-care and post-care instructions to achieve optimal results from FM’s Stretch Mark & Scar Camouflage treatment.
I understand and acknowledge that risk is also present when FM deposits pigments over scars. I understand that the pigment 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, and the scar itself may appear as a dark line on my body. 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 Stretch Mark & Scar Camouflage procedure 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 entire body.
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 Stretch Mark & Scar Camouflage 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 am aware that pigments may fade or discolor over time, and that I may need a touchup procedure in the near future, if a candidate for such procedure. I accept any and all risks associated with FM and the Technician’s Stretch Mark & Scar Camouflage 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 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 that all payments and deposits are non-refundable.
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 Stretch Mark & Scar Camouflage 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, smoke, caffeine, and sun prior or subsequent to receiving any Stretch Mark & Scar Camouflage procedure from FM, as these substances may impair the Stretch Mark & Scar Camouflage process or interfere, distort, or otherwise adversely affect the final result of any Stretch Mark & Scar Camouflage procedure FM administers to me. I further understand, acknowledge, agree, and accept the risk of disregarding FM’s warning that for the first two to three months following Stretch Mark & Scar Camouflage 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 every one of the preceding acknowledgements (collectively, the “Acknowledgements,” and individually an “Acknowledgement”), understands and agrees that Recipient acknowledges and accepts all risks identified in each and every Acknowledgement, and that Recipient waives, shall waive, forever release, and agree to never pursue any and all claims arising from any Acknowledgement as it relates to the Stretch Mark & Scar Camouflage 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 Stretch Mark & Scar Camouflage 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.
Date: June 25, 2022