Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Date of Birth *

Under the age of 18 parental signature is required.

MM

DD

YYYY

Phone *

(###)

###

####

Home Address *

Must match your state ID

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you had Botox or fillers in the last 4 weeks? *

Yes

No

Medical History *

In order to ensure the health and safety of our staff and clients, please answer the following questions truthfully and to the best of your knowledge. Select as needed. Your responses will be kept confidential.

Heart condition

Epilepsy and/or seizures

Herpes (lips)

Ocular herpes

Shortness of breath

Accutane treatment

TCA/Peel

Retinol/Retinoid facial products

Other prescription facial products

Steroid medication

Autoimmune disorder

Alopecia

Hemophilia (excessive bleeding)

Radiation

Chemotherapy

History with skin disease or sensitivities

Diabetes

Hepatitis

Jaundice

Stroke

HIV

Chest pains

Kidney disease

Keloid scarring

Prolonged healing times

Laser removal

Alkaline removal

Refractive eye surgery

Glaucoma

Hyperpigmentation

Trichotillomania

Cancer

Currently pregnant or trying

Currently breastfeeding

Metal allergy

Terms and Conditons *

I have informed the practitioner Mai N Huynh of any and all of my known allergies and health issues. I acknowledge it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the topical preparations or processes used in the procedure and I agree to accept the risk that such reaction is possible. I acknowledge that the nature and method of the proposed pigment (tattoo) procedure has been explained to me, including risks or possibility of complications during or following the procedure and that the other adverse side effects may include: minor and temporary bleeding, bruising, redness, or other discoloration and swelling. Secondary infection in the area of the procedure may occur, however if properly cared for, this is rare. I realize that my body is unique and that hyper-pigmentation (darkening of the skin), hypo-pigmentation (absence of color in the skin), or other damage to the skin may occur during this process and may be permanent. I understand neither Mai N Huynh or Clean Beauty Quyen, LLC can predict how my skin may react as a result of the procedure. I understand that darker skin types (type V & VI above) are at higher risk for hyper-pigmentation and hypo-pigmentation than other skin types. I understand that several treatments may be needed in order to attempt to achieve my desired results. I understand that Mai N Huynh or Clean Beauty Quyen, LLC cannot predict the results in advance and CANNOT GUARANTEE AND HAS NOT REPRESENTED that the results will be as I desire. I understand and fully accept the risks associated with this procedure and do not hold Mai N Huynh or Clean Beauty Quyen, LLC liable. I consent to any relevant photographs/videos being taken both before and after the procedure, to document the results of the procedure strictly for internal use by Mai N Huynh. I consent to Mai N Huynh or Clean Beauty Quyen, LLC using “before & after” photos /videos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting Mai N Huynh or Clean Beauty Quyen, LLC in writing, which will then discontinue use of said photo(s) and or video(s). I consent to the admittance of authorized observers to the procedure(s) for the purpose of education, marketing or assistance. I acknowledge that obtaining this procedure is my choice and my choice alone and I consent to the procedure and its attendant risks, and to any actions or conduct of Mai N Huynh or Clean Beauty Quyen, LLC reasonably necessary to perform the procedure. I have been given the full opportunity to ask any and all questions which I might have about obtaining this procedure from specialist Mai N Huynh at Clean Beauty Quyen, LLC and all of my questions have been answered to my full and total satisfaction. I have been given detailed information regarding this type of procedure, what to expect, contradictions and aftercare instructions. I understand that there will be NO refunds after treatment of this elective procedure or procedures under any circumstances. I understand there is a fee for this session and additional fees for all additional sessions. The fees have been explained to me and I agree to all fees. I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color. I understand that sun, tanning beds, pools, some skin care products and medications can affect the pigment holding and should be avoided. I accept full responsibility to explain to my desire for specific colors, shape, and position for any procedure done. I understand that implanted pigment color can/may slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and/or a touch up session(s). I acknowledge that the proposed procedure(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.

BY SELECTING THIS BOX I ACCEPT THE TERMS AND CONDITIONS.