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Acknowledgment of Informed Consent for SMP Services

*NOTICE: The safety of tattoo inks, dyes, and pigments not approved by the federal Food and Drug Administration is unknown.

Please read the following statements carefully and indicate your understanding and agreement by checking the boxes below before providing your signature. By receiving Scalp Micro Pigmentation services from Ricardo Sepeda, a practitioner at Calaveras Barber Shop & SMP, LLC you confirm your understanding of each statement by initialing beside them:

I understand that I am receiving body art services from Ricardo Sepeda at Calaveras Barber Shop & SMP.

I acknowledge that the Calaveras Barber Shop & SMP includes its employees, apprentices, and agents.

Before-and-After Photos, to also include recording, videography and/or audiotape:I agree to grant Calaveras Barber Shop & SMP LLC permission to photograph, record, videotape, and/or audiotape me undergoing the entire phase of my SMP procedure (collectively as the “recordings”). I further agree to waive any and all rights to the recordings, and further assign my rights of initialing this section, I grant this consent, and further understand and agree that no monetary or other consideration is owed to me by Calaveras Barber Shop & SMP LLC or any other party in respect of the grant of this consent or use and distribution of the recordings.

Use of Photos on Social Media and Website: I understand that the Calaveras Barber Shop & SMP may use these photos on their social media platforms and website for promotional purposes.

I have presented legal identification confirming that I am at least 18 years old.

I affirm that I am not under the influence of alcohol or drugs and am electing to receive body art services willingly without any force, duress or coercion.

The medical history provided by me is accurate to the best of my knowledge.

I comprehend that SMP (body art) is permanent, removal may be costly and may cause scarring at the site of the procedure.

The details of the SMP (body art) agreed upon are accurately reflected in my client record form.

All inquiries regarding the SMP process have been satisfactorily addressed, and written aftercare instructions have been provided to me.

I understand limitations on activities such as bathing, swimming, gardening, contact with animals, etc., along with their duration post-procedure.

I understand that any medical information disclosed will be protected under federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations.

*I am aware that tattoo inks, dyes, and pigments used on the procedure site have not been approved by the federal Food and Drug Administration, and that the health consequences of using these products are unknown.

I have been made aware of the signs and infection indicators such as redness/ swelling/ tenderness at site; red streaks towards heart; fever; or discharge from procedure site.

I acknowledge that there is a risk of infection associated with receiving body art, especially if I fail to properly care for the procedure site.

I commit to seeking medical attention if infection symptoms arise.

I commit to adhering to all instructions regarding the care of my SMP tattoo, and I understand that any necessary touch-ups resulting from my own negligence will be my financial responsibility.

I was made aware that there is a chance that I may feel lightheadedness/dizziness during/after this procedure.

Results and Expectations: I understand that the results of SMP may vary depending on factors such as skin type, hair color, and individual healing processes. While SMP can create the appearance of fuller hair density and camouflage areas of hair loss, it may not replicate the exact look of natural hair follicles, and additional sessions, grooming or maintenance may be required to maintain the desired aesthetic.

I agree to the terms outlined in this agreement.

I have received complete information about the risks associated with a Scalp Micropigmentation (SMP) procedure. These risks include but are not limited to infection, scarring, challenges in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Despite being aware of these potential risks, I choose to proceed with the body art application and willingly assume any and all risks that may arise from this procedure.

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*By selecting checkmark, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement.