Disclosure and Consent Form For Cosmetic Tattoo Procedures

This information is not meant to scare you only to better inform you. These side affects are rare
but could include the following:

Infection - Whenever the skin is opened there is a risk of infection. After the procedure we will
supply you with antibacterial cleanser and a healing ointment to take home. If you follow the
after care instructions the risk of infection is minimal.

Scarring - Scars are areas of fibrous tissue that replace normal skin after an injury. The tattoo
is an injury to your skin.

Hyperpigmentation - Hyperpigmentation is darkening of the skin caused by increased melanin.
Injury to the skin could cause Hyperpigmentation.

Hypopigmentation - is scarring that turns lighter than the skin around it.

Color Migration - When the pigment moves outside the area where it is implanted.

Allergic Reaction - An allergic reaction occurs when the skin senses a foreign body, in this case
the pigment, and overreacts by rejecting it. Allergic reaction could happen immediately after a
procedure or years later if your body decides to respond to the foreign substance. The risk of an
allergic reaction is minimal and you are welcome to come n for a skin test prior to your procedure.

Corneal Abrasion - An irritation on the surface of the cornea, usually a foreign body sensation.
Every precaution will be taken to prevent this from occurring but it is a risk with so much work
being done around the eye area.

Conjunctivitis - An inflammation of the conjunctiva or outermost layer of the eye. Treatable
with antibiotic eye drops.

Milia - White bumps that form when skin cells become trapped and do not exfoliate naturally.
They look like tiny white pimple and in most cases can be removed by scratching the surface
to release them.

Cold Sores - Watery blisters on the lip usually triggered by stress, injury or sun exposure.
Although you cannot cure or prevent a cold sore from occurring you can take steps to reduce the
risk and limit the duration of an outbreak with medication. Call your doctor or dentist and ask
about Zovirax or Acyclovir.

Pain or Discomfort - Topical anesthetics will be applied throughout the procedure to control the
pain although each person has a different level of pain tolerance.

I have read the information form and understand its contents. I understand there are risks involved
with the application of cosmetic tattoos. I except full responsibility for the risks associated with my
cosmetic tattoo. I agree that any controversy or claim arising out of or relating to this content
and/or signed contract between myself and Michele Little shall be settled be arbitration in the state
of California in accordance with the Commercial Industry Rules of American Arbitration
Association and judgment of the award rendered by the arbitrators may be entered in any court
having jurisdiction.

Signature Date


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