Client Consent Form | Kiss and Tell Bombshell

Consent, Disclosure and Medical History Form.

Prior to filling out the consent form download and read the PDF disclosure of your elected procedure located on this page.

I agree to the use of Digital Electronic Signatures on this form below. I understand that all of my answers will be sent to Kiss and Tell Bombshell and digitally logged as a legal representation of my agreement to the terms set forth: *

YES, I agree to the use of electronic signatures
I DO NOT UNDERSTAND WHAT AN ELECTRONIC SIGNATURE IS (if you choose this answer, do not continue. Please call 1-714-970-4912 for explanation)

Todays Date *

First Name *

Last Name *

Date of Birth *

Phone Number *

Email address *

Complete Address *

I have been informed about the chosen procedure and have had the opportunity to ask questions and have read the information provided me on the website, I understand fully the pros and cons or side affects of the procedure I am electing. - Initial *

I hereby authorize the technician of Kiss and Tell Bombshell to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.- Initial *

I hereby authorize the technician of Kiss and Tell Bombshell to take photographs of the work performed both before and after treatment to be maintained only in file.- Initial *

Choose One: I have informed the technician of Kiss and Tell Bombshell that I am in good health and not under the care of any physician. (If no please provide details ) *

Yes
No

Describe: I am currently under the care of a physician and I am being treated for the following condition(s):

Physicians Name

Physicians Phone Number

Physicians Address

I have been made aware that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results. - Initial *

Choose one: I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify possible reactions *

Yes
No
Does not apply to my procedure.

Choose one: Spot testing does not identify individuals who may have a delayed allergic reaction to pigment or people who are a 5 or 6 on the Fitzpatrick scale from scaring from the plasma fibroblast procedure. *

Yes RECEIVE a spot test prior to application and I agree to release the technician of Kiss and Tell bombshell and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments or treamtmet
No WAIVE a spot test prior to application and I agree to release the technician of Kiss and Tell Bombshell and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments or scaring from the treatment

Choose one: I understand that if I have Oily Skin that my strokes may not heal as crisp secondary to the overactive sebaceous glands in my skin (Pertains to permanent makeup procedures using pigment such as lip blushing nano eyebrows or SMP) *

Yes
No
Does not apply to my procedure

I acknowledge that obtaining this procedure is my choice alone. The application of the procedure will result in a permanent change to my appearance, and that No representations have been made to me as to the ability to later restore the skin - Initial *

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia, bleeding disorder. or cardiac valve disease. - Initial *

If I suffer from hepatitis, or other risk factors for blood borne pathogen exposure, or any other communicable disease, I have informed the technician of Kiss and Tell Bombshell of the fact and have been advised of any medications and procedure necessary *

I have advised the technician of Kiss and Tell Bombshell of any allergies to latex gloves, soap, or medications. I acknowledge it is not reasonable for the technician to determine whether I might have an allergic reactions. - Initial *

I acknowledge infection is always possible as a result of any procedure, and I agree to follow all aftercare instructions. If infection occurs I will notify the technician, and my physician. - Initial *

I understand my technician will use appropriate instruments and sterilization techniques. I have been informed of how long my procedure takes to heal. - Initial *

I understand that inks, dyes, pigments, plasma fibroblast, Hyaluron Pen and fat dissolvers have not been approved by the Federal Food Administration and that the health consequences of using these products are unknown.- Initial *

I have been made aware that this procedure may involve pain and discomfort by my technician may apply numbing cream as needed. - Initial *

I have been made aware that a follow up procedure may be required. - Initial *

I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me. - Initial *

I agree, should I have a discrepancy of any kind, I shall first notify my technician of Kiss and Tell Bombshell for resolution- Initial *

I have been told, read, downloaded or handed a copy of the aftercare instructions. I fully understand them and agree to follow them for proper healing from my procedure - Initial *

Medical history section for: (Your full name) *

Employer:

Occupation:

Are you now or have you been under the care of a physician within the last two years? *

Yes
No

Person to contact in an emergency (Contacts name) *

Emergency contacts phone number *

List all medications you are currently taking, including Retin A, Glycolic Acid and Acutane: *

List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams): *

Have you recently undergone a skin peel? *

Yes
No

What products do you use for skin care? *

I agree to release and hold harmless, the technician, management and owners of Kiss and Tell Bombshell from all claims of negligence, damages, or legal actions arising my elected procedure - Initial *

By Typing Full Name you agree under penalty of perjury that: I am over the age of 18 years of age, I have answered all questions truthfully and honestly, I understand and have been informed of the procedures I am electing to have performed possible risks. *

Date of Consent *

Technicians Name Linda Marie Ellis *

Yes
No
Other

Name of Other Technician

By submitting this consent form you are indicating you have been informed about the procedure you are elected to have done. Mark yes or no if you have downloaded the disclosure of your procedure in addition to being informed. *

Yes
No

Send me a copy

Plasma Fibroblast Skin Tightening Disclosure - Before and After Treatment Protocol

KATB Plasma Fibroblast Disclosure Before And After Care Protocol

PDF – 532.6 KB 163 downloads

Download

Hyaluron Pen Lip and Wrinkle Fillers and Fat Dissolver Disclosure - Before and After Treatment Protocol

KATB-Lip-fillers-fat-disolver-disclosure-with-hyaluron-pen

PDF – 749.7 KB 180 downloads

Download

SMP - Scalp Micropigmentation Disclosure - Before and After Treatment Protocol

KATB SMP Scalp Microigmentation Disclosure Before After Protocol

PDF – 423.9 KB 182 downloads

Download

Brows, Lip Blushing and BB - Glow Disclosure - Before and After Treatment Protocol

KATB Permanent Makeup Procedure Before After Protocol

PDF – 866.5 KB 164 downloads

Download

Tattoo Removal with Plasma Pen Disclosure - Before and After Treatment Protocol