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The Peach Club Disclosure & Release Agreement for cosmetic tattooing with Meg Baker and COVID-19 safety

Please take a moment to complete our “Disclosure & Release Agreement” completely, making certain that you understand all information provided, and that your information is correct.

You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure.

By submitting the form below you agree to knowingly and willingly consent to have a skin service during the COVID-19 pandemic. We reserve the right to refuse treatment if this form is not submitted.

The Peach Club is a safe, peaceful space and all are welcome

Please fill your name: *

Please enter your full name.

Date of Birth: *

Please enter valid date.

Phone number: * Please enter your phone number.

Please let us know if there is anything we can do to make you feel comfortable and safe during your visit to our space. Please enter your answer here.

Please select your procedure *

Lip Blush

Eyeliner

Freckles

Eyebrows

Please select at least one choice above.

Are you allergic to any of the following

Latex rubber

Lidocaine

Metals

Please select at least one choice above.

Do you have high or low blood pressure

Please select at least one choice above.

Suffer from seizures, if YES please describe

Please select at least one choice above.

Have heart palpitations, if YES please describe

Please select at least one choice above.

Have autoimmune disorders, if YES please describe

Please select at least one choice above.

Had a HIV text, result

Please select at least one choice above.

Do you have hepatitis A, B or C D if YES please advise below

Please select at least one choice above.

Have you had any surgeries or disorders

Please select at least one choice above.

Are you taking any medications if YES please list

Please select at least one choice above.

Under physician’s care for a condition. Please describe

Please select at least one choice above.

Do you have any facial fillers, if YES where

Please select at least one choice above.

Use retain A, glycolic or any other AHA skin products (pigmentation) is YES please list

Please select at least one choice above.

Do you have any other dermal disorders such as eczema, dermatitis, psoriasis, rosacea, acne and skin cancers, if YES please list

Please select at least one choice above.

By selecting you agree that:

Please select at least one choice above.

By checking this box, I agree that no food, drinks, or making/receiving phone calls are allowed in the procedure area. Minimal texting or email is totally fine, as long as it does not interfere with the procedure * Please check it here.

By checking this box, I agree no warranty has been made to me as a result of this semi permanent makeup, micropigmentation or correction procedure, and that the final result cannot be guaranteed. * Please check it here.

By checking this box, I agree there may be risk of infection if aftercare instructions are not followed * Please check it here.

By checking this box, I realise that there is potential for discomfort during the procedure and during the healing process * Please check it here.

By checking this box, I agree there is a possibility of bleeding, swelling, and allergic reactions to the pigments used * Please check it here.

By checking this box, I agree Cosmetic tattooing is considered semi-permanent, and will fade with time * Please check it here.

By checking this box, I agree a tattoo can only be removed with surgical or laser procedures, and that any effective removal may leave permanent scarring or disfigurement * Please check it here.

By checking this box, I agree misplacement or migration of the pigment can occur, under rare circumstances, requiring excision and/or correction of the misplaced pigment * Please check it here.

I have reviewed the FAQ & Policies sections on www.thepeachclub.com.au prior to my appointment, and I understand the info there, and have had any further questions I've had answered * Please check it here.

I agree that my technician will not, under any circumstance, perform any procedures on me if I am known to have any allergies related to the products used * Please check it here.

I understand that I must inform my technician of any and all medication(s) I am currently taking. (Pain control medications such as aspirin or ibuprofen may cause the blood to thin, and excessive bleeding may occur during or after the procedure * Please check it here.

I do not currently take Accutane and/or have not taken for at least 12 months * Please check it here.

I understand that I must inform my technician of any skin condition(s) I may have. (Psoriasis, Eczema, etc * Please check it here.

I understand that it is my responsibility to advise the technician of any concerns I may have before they begin the procedure * Please check it here.

I am not under the influence of any drugs or alcohol * Please check it here.

I am not pregnant * Please check it here.

I am actually reading these and not just ticking every box * Please check it here.

I release the studio and its representatives and subsidiaries of all claims for injury, seen or unseen, that may occur as a result of this procedure * Please check it here.

I fully understand the questions, terms, and conditions of this Disclosure & Release Agreement. I accept to waive my rights for any claim against the technician for any reason whatsoever. * Please check it here.

I believe that I have sufficient information to give this informed consent * Please check it here.

I certify that this Disclosure & Release Agreement was completed by me and that all entries and information are true and complete to the best of my knowledge * Please check it here.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing. * Please check it here.

By checking this box I confirm that I am not presenting any of the following symptoms of COVOID-19 listed • Temperature above 37.4°C • Shortness of breath • Loss of sense of taste or smell • Dry cough • Sore Throat * Please check it here.

I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of hair services, that I have an elevated risk of contracting the virus simply by being in the studio.. * Please check it here.

I confirm that I have not been around anyone with these symptoms in the past 14 days. * Please check it here.

I do not live with anyone who is sick or quarantined. * Please check it here.

To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the salon’s strict guidelines. * Please check it here.

Please note that photos are taken for insurance purposes as well as social media. Your before/after photo to be shown on social media (Instagram/Facebook/etc.) and in printed materials will only be of your procedure not your entire face unless stated otherwise. (Your face will not be shown and you will not be tagged in the photo. Just a photo of the work that was done.)

Here’s the part where we talk about shape and colour:

What are you looking for from cosmetic tattoo? In your own words, write exactly what you want from the treatment, include any fears you may have regarding the treatment. * Please enter your answer here.

Acceptance of shape: I do certify that I have been given the opportunity to change the shape, the final shape I agree, is my choice which will be followed. *

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Please sign here.

Acceptance of colour: Colours have been discussed and shown to me and my technician that they cannot get the exact colour. I certify that we have agrees on the following colour choice. *

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Please sign here.

Acceptance of lighter colour and thin eyebrows: It has been explained to me that this is my request to have a lighter colour implanted for eyebrows and it has been made clear to me the importance of having the adjustment appointment within 4 months from the initial treatment. The longevity of lighter colour and thin brows implanted is substantially less than stronger darker suggested within 15 months. *

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Please sign here.

Topical aesthetic informed consent. I do not have any known allergies to local anaesthetic creams or PABA (sunscreen). I have no reason why I cannot receive a topical aesthetic to prevent or reduce discomfort during my procedure. I have never had any adverse reaction to local anaesthetic administered in a Dentist’s office during surgical procedure. I understand that there is a wide variation in effectiveness and duration of topically applied anaesthetics. I hereby request the use of a topical anaesthetic preparation which contains Lignocaine, Procaine and Tetrecaine and understand that I may experience redness, itching or swelling with the use of topical anaesthetic. Local anaesthetic preparations are use in sunburn, diaper rash, poison oak/ivy, hemorrhoid and many preparations available at the chemist over-the-counter. I also understand and agree that complications can occur during a Cosmetic tattoo procedure and will follow the instructions of my Practitioner to seek treatment. I accept the use of a topically applied anaesthetic at my own risk for the elective procedure. *

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Please sign here.

AFTERCARE: You will be advised of aftercare available 24/7 on our website and instructed to read thoroughly. I have read and/or been informed of the Home Care Information and understand the procedure I have to follow. *

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Please sign here.

We acknowledges the Wurundjeri Woi Wurrung people of the Kulin Nation as the traditional custodians of the land on which our studio stands. We pay respect to their Elders past, present, and emerging and extend this respect to Aboriginal and Torres Strait people from other communities who are here today.

No Sexism, Racism, Homophobia, Fat Phobia, Transphobia or general hatefullness tolerated in our studio.