Loading...

Ink+Iron Collective/Nicolette Koshaba Artistry LLC

4028 Papermill Drive Ste 12, Knoxville TN

July 2, 2025

The following confidential medical information will be property of Ink+Iron Collective/Nicolette Koshaba Artistry LLC. This is required for the benefit and safety of the client in obtaining any and all procedures performed by Ink+Iron Collective/Nicolette Koshaba Artistry LLC. Please read and fill out the information carefully. We hope your experience will be a pleasant one and we thank you for your cooperation.

I understand that several treatments WILL be needed in order to attempt to achieve my desired results. I have not been given any guarantees as to how much pigment will actually be removed from the skin.


I understand there are other options and methods available for pigment removal/lightning. I have decided to move forward with the Saline removal/lightning.


I will not hold Ink+Iron Collective/Nicolette Koshaba Artistry LLC or it’s practitioners responsible for any resultant failure to remove, partially, totally or to lighten. 


I will not hold Ink+Iron Collective/Nicolette Koshaba Artistry LLC or its practitioners and/or the distributor of tattoo removal products used in this attempted tattoo removal, liable for any damages that may occur to my skin.


I agree to follow all aftercare instructions. I have reviewed all pre- and post- care directions via microbladingbynicolette.com and understand the risks of the procedure in addition to the possible consequences of not adhering to proper aftercare protocol.


I have been informed of the nature, risks, possible complications and consequences as listed above. I further understand that Ink+Iron Collective/Nicolette Koshaba Artistry LLC and its practitioners are not medical professionals and this procedure is an art and not an exact science and have neither asked for nor received any guarantees or promises as to the results obtained.


As these appointments take considerable time, 72 hours of notice is required to reschedule an appointment. I understand that if I cancel with less than 24 hours notice or no-call-no-show, the entire cost of procedure may be forfeited.


I acknowledge by signing this consent form, I have been given the full opportunity to ask any and all questions about saline removal/lightening procedure(s), it’s process, and the risk involved from Ink+Iron Collective/Nicolette Koshaba Artistry LLC and its practitioners. The decision to have saline removal/lightening procedure(s) performed is my own, and I understand and accept all risk involved, therefore releasing Ink+Iron Collective/Nicolette Koshaba Artistry LLC and its practitioners from any liability.Ink+Iron Collective/Nicolette Koshaba Artistry LLC are artists and highly trained, experienced and skilled artists and make no claims to be medical professionals. Saline removal/lightening is not a medical procedure. I understand there are no refunds. I have reviewed and understand the cancellation policies and saline removal information available via microbladingbynicolette.com.

 

July 2, 2025

First Participant's Name
First Name*
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Third Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Fourth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Fifth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Sixth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Seventh Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Eighth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Ninth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Tenth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Please check all that apply
Pregnant/breastfeeding
I am over the age of 18 and in sound mind, body, and health
I use blood thinner (including but not limited to aspirin, rivaroxaban, dabigatran, apixaban, edoxaban)
Have a mental impairment that may affect my judgement
Cold sores, fever blisters or any form of herpes
Allergy to latex
Complications with previous tattoos/permanent makeup
Had laser done to treat the area
I am undergoing chemo and/or radiation
I am anemic
I have complications with healing
I have an allergy or sensitivity to lidocaine or any other numbing agent
Have a history of skin diseases that I will notify my technician of

Where is the location of the tattoo/permanent makeup you desire to remove? Why are you choosing to have this removed? When was your last treatment? How many times has this area been tattooed? Who was the artist (artists) to perform this work we are removing? Please describe to the best of your ability. *

List any medications, both prescription and over the counter that you are taking

Please list all allergies and conditions (including but not limited to cancer, AIDS, herpes, hepatitis, heart conditions, diabetes, hyperpigmentation, hypopigmentation, hemophelia, or history of strokes)
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!