PRETTY IN INK CONFIDENTIAL CONSENT AND RELEASE AGREEMENT PLEASE PRINT Name/Releasor: ________________________________ Today’s Date: _________ D.O.B.: __________ Home Phone: ____________________ Address: __________________________________________________City, State, Zip: _______________________________________________ Cell Phone Number: _________________________________________ Email: ______________________________________________________ MEDICAL HISTORY Please circle “yes” or “no” as applicable : Diabetes ……………………… Eye Disease…………………… Yes No Do you use Acutane?………………. Yes No Epilepsy……………. ………… Yes No HIV…………………………… Yes No Are you at least 18 years old?…….…. Yes No Keloid Formation……………. Yes No Autoimmune Disease………… Yes No Do you have any tattoos?……. Yes No Hemophiliac…………………. Yes No Blood Disease…………………. Yes No Have you had plastic surgery?………. Yes No Active Skin Disease…………. Yes No Pregnant or Nursing…………. Yes No Do you plan to have plastic surgery?… Yes No Hepatitis……………………… Yes No Alopecia………………………. Yes No Do you wear contact lenses?….…. Cancer………………………… Yes No Alcohol consumption…….… Yes No Do you use glycolic acids?. Yes No Heart Condition……………… Yes No High or Low Blood Pressure… Yes No Do you use Retin-A?………………… Genital Herpes…………….… Yes No Pacemaker…………………… Yes No Do you smoke?……………………… Glaucoma……………………. Yes No Cold Sores……………………. Yes No Do you like to tan?: …………… Yes No If there is any other medical history not mentioned above, please list: ____________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Are you currently under a doctor’s care? Yes No Explain: _________________________________________________________________________________ Are you taking any medications? Yes No Please List: _________________________________________________________________________________ Do you have any allergies? Yes No Explain: ________________________________________________________________________________ Have you ever had an adverse reaction to cosmetics? Yes No Explain: _________________________________________________________________________ This Agreement is entered into by the above named Releasor and PRETTY IN INK, hereinafter know as the Releasee: 1. The Releasor fully and voluntarily consents to have the Releasee perform cosmetic tattoo procedure(s) and is fully aware and informed of any and all inherent risks, dangers and complications that may occur as a result of the procedure(s), which may include, but are not limited to: scarring, infections, allergic reactions, corneal abrasions, herpes (cold sore) outbreaks, eye injury, swelling, pain, bruising, minor bleeding, redness, soreness, hyper-pigmentation, etc. The Releasor understands that the cosmetic tattoo procedure is an art, not an exact science, and that the tattoo(s) may not appear exactly as the Releasor anticipates. 2. The Releasor acknowledges that all questions have been answered and all known risks, dangers and complications have been explained and hereby agrees to forever release the Releasee from all claims, damages or liabilities that may result from the cosmetics tattoos as described in this Agreement, including costs of medical care that may arise from the procedure, including post-procedure care. The Releasor acknowledges that the Releasee has made no claims, representations or guarantees, other than as expressly stated herein. 3. The Releasor agrees to accept full responsibility for each and every procedure that the Releasor asks the Releasee to perform, including, but not limited to: Eyebrows, Eyeliner, Lash Line Enhancement, Lips, Beauty Marks, Scar Camouflage and Areola Restoration. The Releasor understands that it is unlikely, if not impossible, that the Releasee will be able to make any of the procedures perfectly symmetrical. In other words, for example, the Releasee cannot expect one eyeliner or eyebrow to look exactly like its “sister.” The Releasor acknowledges that he/she has received, read, and discussed with the Releasee instructions regarding post-procedure care, Releasor understands said instructions and agrees to follow such instructions to help prevent secondary infection. 4. The Releasor CONSENTS TO / WAIVES (circle one) a patch test prior to the procedure to assess the likelihood that the Releasor will have an allergic reaction to the pigments to be used by the Releasee.
5. The Releasor acknowledges that cosmetic pigments can heal inconsistently, spread or fan, and can and will fade. It is the Releasor’s responsibility to schedule a touch-up to be done three to six weeks after the initial procedure. This touch up will be done at no cost to the Releasor if scheduled within said time period. After six weeks, the Releasor agrees to pay a service fee for any and all future touch-ups. 6. The Releasor understands that the cosmetic tattoo(s) will appear thicker and darker immediately after the procedure than it will one week later. Within three to four days after the procedure, the outer layer of pigment will begin to slough off and the tattoo will then appear lighter, softer and less defined. 7. The Releasor understands that: (i) he/she should not donate blood for one year following a tattoo procedure; (ii) tattoo removal can be costly and painful; (iii) he/she should advise medical personnel or professional estheticians of the existence of the cosmetic tattoo if a chemical peel, MRI, or plastic surgery is to be performed near or over the cosmetic tattoo; (iv) he/she should obtain a prescription for Zovirax, Valtrex or some other prescription cold sore medication to prevent the onset or spread of cold sores during a lip procedure; (v) sun, chlorine water, glycolic acids and microdermabrasion may fade or otherwise effect the color of the pigments; (vi) anything applied to the procedure area within two (2) weeks after the procedure may cause an infection; and (vii) he/she should not wear contact lenses during an eyeliner/eyelash line enhancement procedure. I hereby authorize PRETTY IN INK to perform the following procedures: ______ Eyebrows _____ Upper Eyeliner/Eyelash Line/Wet Line Enhancement ______ Lower Eyeliner/Eyelash Line/Wet Line Enhancement ______ Lip Liner ______ Lip Fill ______ Lip Augmentation ______Beauty Mark ______ Scar Camouflage ______ Areola Restoration Please read and initial: ______I consent to the use of my before and after photographs for advertising purposes. ______I have received, read, and understand the aftercare instructions. I certify that I have read and fully understand this Confidential Consent and Release Agreement, and that I accept full responsibility for any complications which may arise during or after the cosmetic tattoo procedure that the Releasee is to perform at my request. I also understand and affirm that the Releasee has not provided any warranty or guarantee regarding the outcome of the procedure. (If the Releasor is under the age of 18, a Parent or Guardian must sign on behalf of the Releasor.) Signature of Releasor: ___________________________________________________ Date: _____________________________ Signature of Releasee: ___________________________________________________ Date: _____________________________ FOR OFFICE USE ONLY Procedure Performed: _____ Eyebrows ______Upper Eyeliner/Lash Line/Wet Line Enhancement ______Lower Eyeliner/Lash Line/Wet Line Enhancement ______Lip Liner ______ Lip Fill _____ Beauty Mark _____ Scar Camouflage ______ Right Areola _____ Left Areola Color Used: ____________________________________ for: _________________________________ Date: ________________ Brand: ________________________________________ Lot#: ____________________________Exp. Date: ________________ Color Used: ____________________________________ for: _________________________________ Date: ________________ Brand: ________________________________________ Lot#: ____________________________Exp. Date: ________________ Color Used: ____________________________________ for: _________________________________ Date: ________________ Brand: ________________________________________ Lot#: ____________________________Exp. Date: ________________ Anesthetic: ____________________________________ Lot#: ____________________________ Exp. Date: ________________ Anesthetic: ____________________________________ Lot#: ____________________________ Exp. Date: ________________ Anesthetic: ____________________________________ Lot#: ____________________________ Exp. Date: ________________ Location where procedure(s) performed: ________________________________________________________________________ Comments: _________________________________________________________________________________________________
Effects of childhood body size on breast cancer tumour characteristics Jingmei Li1,2, Keith Humphreys1, Louise Eriksson1, Kamila Czene1, Jianjun Liu2 and Per 1Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, Box 281, 171 2Human Genetics, Genome Institute of Singapore, 60 Biopolis Street, Singapore, 138672, Corresponding author: Jingmei Li, [email protected] A
Expertenchat zum Thema "Leberprobleme" Dr. Lutz Mirow beantwortete Ihre Fragen im Livechat Hallo und herzlich willkommen zu unserem Expertenchat. Heute dreht sich von 11 bis 13 Uhr alles um das Thema Leberprobleme. Als Gesprächspartner steht uns und Ihnen der Chefarzt der Klinik für Allgemein- und Viszeralchirurgie im Krankenhaus Mittweida, Dr. Lutz Mirow, Rede und Antwort. Sie