Ink Consent Form

INK CONSENT FORM

This Ink Consent Agreement (Agreement) is entered into between the parties identified below on the Effective Date. Client Name: and Practitioner/Studio Name: .

Client Address:

Practitioner Address:

RECITALS

WHEREAS, Practitioner is duly qualified, licensed where required, and experienced in the application of permanent or semi-permanent ink procedures and associated aftercare; and

WHEREAS, Client desires to receive an ink procedure and to engage Practitioner under the terms set forth herein; and

WHEREAS, the parties intend for this Agreement to set forth the scope, payment, consent, and risk allocation governing the provision of the services effective as of:

SCOPE OF WORK

Practitioner shall perform the ink procedure described below in accordance with accepted professional standards and the specifications agreed with Client.

PAYMENT TERMS

Client agrees to pay Practitioner the amounts and on the schedule set forth below. All amounts are denominated in U.S. dollars unless otherwise indicated.

TERM AND TERMINATION

This Agreement commences on Start Date: and continues until End Date: unless earlier terminated as provided herein.

Either party may terminate for convenience upon written notice delivered no fewer than days prior to the intended termination date. Practitioner may terminate immediately for material breach or safety concerns.

CONFIDENTIALITY

The parties acknowledge that Client medical information, allergy information, and any sensitive personal information disclosed in connection with the services is confidential. Practitioner shall not disclose Client's confidential information except as required by law or as necessary to provide aftercare or emergency medical treatment.

Client acknowledges and consents to the use of non-identifying procedural photographs for Practitioner records and for Practitioner promotional use only if the Client has given express consent below.

I acknowledge the confidentiality provisions above and consent to the limited uses described.

I consent to before-and-after photographs for clinical records.

RISKS, REPRESENTATIONS AND CONSENT

Client acknowledges receipt of and has read the risk disclosure describing potential adverse outcomes including infection, scarring, allergic reaction, pigment migration, color change, and the potential need for touch-ups or removal. Client further acknowledges that results cannot be guaranteed.

By checking the boxes and signing below, Client represents and warrants that Client has disclosed all known medical conditions, allergies, pregnancy status, medications (including blood thinners), and any history of keloid scarring.

I confirm I have disclosed all relevant health information and understand the risks.

I hereby consent to the ink procedure described in Scope of Work and authorize Practitioner to perform the procedure.

LIABILITY AND INDEMNIFICATION

Client releases Practitioner from liability for ordinary negligence in connection with the performance of the services to the fullest extent permitted by law, except in the case of gross negligence or willful misconduct. Client agrees to indemnify and hold Practitioner harmless from claims arising from Client's failure to follow aftercare instructions or from undisclosed medical conditions.

I acknowledge the liability and indemnification provisions above.

GOVERNING LAW; ENTIRE AGREEMENT

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

This Agreement, together with any written attachments and the Scope of Work, constitutes the entire agreement between the parties and supersedes all prior understandings relating to the subject matter. Any modification must be in writing and signed by both parties.

I acknowledge that this document constitutes the entire agreement as described above.

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