Treatment Consent & Indemnity Form

CLIENT INFORMATION & TREATMENT DETAILS

First name

Last name

Date of Birth

Day

Month

Year

Treatment Date

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Mobile

Emergency Contact:

First Name:

Last Name:

Emergency Mobile phone

Relationship

MEDICATION

Are you currently using Hair Growth Medication?

I understand that I must verbally inform my technician of any concerns, use of medication (including pain medications) or medical conditions I have before receiving MicroChanneling.

USE OF PHOTOS AND/OR REVIEWS

By ticking this box and Signing below, I agree to the following: terms and conditions

Tick any boxes that apply, you MUST tick at least one of them.

Photos showing my full face

Photos showing part of my face

Photos showing NO part of my face

Online Review

CONSENT & SIGNATURE

Consent (Required)

By ticking this box and Signing below, I agree to the following:

BY SIGNING THIS DOCUMENT YOU GIVE UP THE RIGHT TO SUE, AND ASSUME BOTH RISK AND EXTRAORDINARY RISKS INHERENT TO THE SMP Tattoo 3D Areola Tattoo, 3D Belly Button Tattoo, Inkless Stretchmark Revision and Microchanneling TO: GEC REALTY PTY LTD doing business as Hair Ink SMP Gold Coast/Areola Ink.

This Release and Waiver of Liability (the "Release") releases "GEC REALTY PTY LTD." doing business as "Hair Ink SMP

Gold Coast/Areola Ink", a corporation organized and existing under the laws of Australia and each of its directors, principals, officers, employees, and agents. In consideration of receiving a the

"SMP Tattoo", "3D Areola Tattoo", "3D Belly Button Tattoo", "Inkless StretchMark Revision",) and Microchanneling from any tattoo artist at Hair Ink SMP Gold coast/Areola Ink together with its employees, apprentices and/or agents (the "Artists"), the Client AGREES to the following:

1) | have been fully informed of the inherent risks associated with getting the SMP Tattoo, 3D Areola Tattoo, 3D Belly Button, Inkless Stretchmark Revision and Microchanneling

Signature (Required)

Signature

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