Client Waiver Form – Skin Conceal Orlando

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First Name

Last Name

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone *

Email Address *

Date of Birth *

MEDICAL HISTORY

Please answer the following questions honestly and completely.

1. Do you have any active skin conditions (e.g., eczema, psoriasis, dermatitis)? *YesNo

2. Have you had any recent surgeries or injuries in the area to be treated? *YesNo

If yes, please specify

3. Are you prone to keloid scarring? *YesNo

4. Are you currently pregnant or breastfeeding? *YesNo

5. Do you have any blood disorders (e.g., hemophilia) or are you on blood-thinning medications? *YesNo

6. Are you immunocompromised (e.g., HIV/AIDS, undergoing chemotherapy)? *YesNo

7. Do you have any known allergies to tattoo pigments, latex, or other materials used in the procedure? *YesNo

If yes, please specify

8. Do you currently have any active infections (bacterial, viral, fungal) in the area to be treated? *YesNo

9. Have you recently tanned or had a sunburn in the area to be treated? *YesNo

10. Do you have any autoimmune skin disorders (e.g., lupus, vitiligo)? *YesNo

If yes, please specify

11. Are you diabetic? *YesNo

If yes, is your condition well-controlled?

Please list any other medical conditions or concerns not mentioned above:

Consent

Consent *

The Client understands that the following conditions may contraindicate the procedure:
• Active skin conditions
• Recent surgeries or unhealed scars
• Prone to keloid formation
• Pregnancy or breastfeeding
• Blood disorders or use of blood-thinning medications
• Immunocompromised status
• Allergies to pigments or materials used
• Active infections
• Recent tanning or sunburn
• Autoimmune skin disorders
• Diabetes (if not well-controlled)
• Recent use of Accutane or strong retinoids
By signing this form, the Client acknowledges that they have disclosed all relevant medical information and understand
the contraindications associated with the procedure.

WAIVER AND RELEASE OF LIABILITY

1. Voluntary Participation
The Client acknowledges that their participation in the procedure is entirely voluntary. They have been informed of and
understand the risks involved.

2. Release of Liability
The Client releases and holds harmless the Artist, their affiliates, trainers, manufacturers, and any other associated entities from
any and all liability, claims, demands, or causes of action that may arise from the procedure, including but not limited to personal
injury, property damage, or any other losses incurred as a result of the procedure.

3. No Refund Policy
The Client understands and agrees that all payments made for the procedure are non-refundable. The Client acknowledges that
the Artist cannot guarantee specific results, as individual outcomes may vary.

4. Use of Photos and Likeness
The Client grants the Artist and their representatives the irrevocable right and permission to use, reproduce, edit, publish, and
distribute any photos, videos, or other media that feature the Client’s likeness, image, and appearance. This permission is granted
for all purposes related to the Artist's business, including advertising, promotion, and portfolio display, without any further
compensation or approval required from the Client.

CLIENT ACKNOWLEDGEMENT AND SIGNATURE
By signing below, the Client confirms that they have read and fully understand this Agreement, including the medical history
questions, contraindications, waiver and release of liability, no-refund policy, and the use of photos and likeness. The Client
acknowledges that they have had the opportunity to ask questions and have had those questions answered to their satisfaction.

(689) 299-1204

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