Tattoo Waiver

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    DENTAL ADORNMENTS
    • I understand that the gem and bonding agents may cause an allergic reaction when placed or swallowed, causing redness and swelling of the tissue, pain, itching, vomiting or severe allergic reactions.I understand that the gem may contain some less as in all glass/crystal/metallics
    • I understand that during placement it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during inspection.
    • I understand that this procedure is temporary
    • I understand that the gem is bonded to the enamel.
    • I understand that if I want to remove the gem I will have to go to a dentist and I am responsible for all costs associated withremoval/cleaningI understand that if I whiten my teeth or stain my teeth while wearing the tooth gem that the area beneath the gem will be a different colour and I accept all costs associated with corrections
    • I understand that if the gem(s) fall off that I am solely responsible for the cost of replacing them or removing any adhesive that maybe remaining
    • I agree that the tooth/teeth I am getting the gems placed on is a real and flat tooth/ teeth - If you have a tooth that is a false,crowned, or capped the Tooth Jewel glue will not adhere to the false tooth.
    • I authorize GRIM Studios to apply a Tooth Jewel with Dental Adhesive to my tooth/ teeth and that this/these teeth are real.
    • I understand that this procedure is temporary and on average a gem lasts four months
    • I acknowledge that by signing this agreement that I have been given full opportunity to ask any & all questions I might have aboutobtaining a tattoo, the process, healing, the business and the staff, and that all of my questions have been answered to my fullsatisfaction.
    • I am not pregnant, I do not suspect that I may be pregnant & I am not nursing.
    • I am over the age of 12 years old
    • I am not under the influence of ANY drugs or alcohol.My artist has advised me on location and expected results and I understandthat variations in colour or design may exist.
    • I do not have any mental, physical or medical impairment or disability which may affect my well being as a direct or indirect result of my decision to get this procedure
    • I have truthfully represented to my artist that the obtaining of a tooth gem(s) is/are by my choice alone.
    • I consent to the application of the gem(s) and to any actions or conduct of the representatives and employees of the studio that arereasonably necessary to perform the procedure.
    • I consent to ALL terms laid out in GRIM Studios’ Policy and that if I have misrepresented ANY term in this agreement that I, aloneaccept full responsibility of any and all consequences of my actions.
    • I agree to release & forever discharge & hold harmless GRIM Studios, Grim City Tattoo Inc. & all independent contractors or employees from any claims, damages or legal actions arising from or connected in any way to my procedure or the procedure and conduct used.
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    BODY MODIFICATIONS

    • Please read this consent form entirely. The ultrasonic cavitation treatment uses 40KHz frequency ultrasound to penetrate the skin and assist your body in breaking down fat cells. Multiple sessions may be required to achieve desired results at an additional cost. Ultrasound Cavitation carries possible health risks and complications including but not limited to kidney failure, liver failure, pacemaker failure, birth defects, miscarriage, thyroid damage, ovary damage, hyper-tryglyceridemia, hyper-cholesterolemia, pancreatitis, infections, scarring, and/or allergic reactions to any products used during the treatment(s).
    • I understand that fat cavitation treatments are not recommended if I am pregnant, breast feeding, have a lymphatic disorder, acute illness, metal implants, pacemaker, or are currently being treated for active cancer.
    • I understand that this agreement does NOT provide a guarantee of results nor does the practitioner in which I am voluntarily seeking services. This agreement deals solely with the services to be rendered and the fees to be paid for the care as provided. Your payment obligation is not contingent upon the outcome of services.
    • I understand that the practitioner is using a high-power low-frequency 40KHz machine on me during this service and the machine has a mild ringing noise when using it.
    • I understand and acknowledge that payments for the above services are non-refundable.
    • ​By my signature below, I certify that I have read and understand the contents of this consent form.
    • I further agree to provide the practitioner 24 hour notice of a cancellation or change in appointment time, or I will forfeit a treatment off my package since treatments are by appointment only.
    • There are no refunds if I am responding to a treatment and decide to stop treatments.
    • Should I decide to add a treatment, that treatment will be considered an additional and separate treatment.
    • I agree to inform and notify immediately the practitioner should any information regarding my health history past and present change.
    • I agree that I have answered all the questions about myself and health history to the best of my abilities and knowledge.
    • I certify that the information on my cavitation intake form is true, and acknowledge that any misrepresentation of my health history may result in injury or death. If any of the information about me or my health history is false, misleading, or undisclosed, I agree that the practitioner will not be held liable.
    • I understand all of the possible complications and risks associated with the Fat Cavitation Procedure and voluntarily elect to proceed. I agree that all of my questions have been answered to my satisfaction.
    • I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing and elect to receive voluntarily the Radio Frequency Treatment.
    • I have been informed of the nature, risks, and possible complications and consequences of Radio Frequency therapy. I understand the Radio Frequency Treatment may have known or unknown complications including but not limited to: increased inflammation, redness, and rashes although these side effects are rare.
    • I give permission to "COMPANY NAME HERE" to perform the Radio Frequency treatment on me.
    • I request the Radio Frequency treatment and accept the possible complications and consequences.
    • I agree that I am not currently taking any medications that cause photosensitivity/light sensitivity, am not epileptic, or have a history of seizure disorder
    If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement.​

    eSignature

    ​The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.