This information is provided in addition to the information you have already received prior to your treatment day. (This includes the Client Personal Medical Record and the information provided both in consultation and on the website scalpmicrousa.com). This information has been designed so that you can make an informed decision whether or not to give informed consent to the Scalp Micropigmentation treatment. Please, therefore, ensure that you have read and understood this form, the documents mentioned above and the information provided to you during your consultation. Only sign the attached Personal Medical Record if you are happy to proceed with the Scalp Micropigmentation treatment with Scalp Micro USA. You have the right to change your mind at any time before beginning treatment, including after you have signed the attached form. • The SMP treatment is an elective treatment and there is no medical reason that requires a client to proceed with the treatment • The SMP treatment is a form of tattoo and uses a pigmentation procedure to apply colorants just below the skin in the dermis, in a similar manner to traditional tattoos. Like traditional tattoos, the markings can be difficult to remove and the success of any removal procedure cannot be guaranteed • The colorants used in the SMP treatment are made with natural ingredients (carbon and iron oxide). • Clients may experience some discomfort (possibly pain in rare cases) during the SMP treatment. • As with any tattoo treatment, there is a risk of infection, although serious infection is very rare. • Clients with a history of skin cancer, sun damaged skin or any other relevant medical condition should consult their PGP/Physician before undergoing the SMP treatment. In these circumstances, we may require a signed certificate from the client’s PGP before starting treatment. • To obtain the best results, the client must comply with our aftercare advice as described in our literature and must attend any follow-up appointments advised by our staff. • If clients tamper with the SMP procedure whilst undergoing treatment sessions (included failure to return for necessary follow-up sessions as originally outlined), this will void the Scalp Micro USA LLC guarantee against potential fading. Cancellations, payments, & complaints We will notify you with the time and date of your treatment appointment. On receipt of this notification please confirm your attendance. Failure to do so may result in the reallocation of the appointment time to another client. Any and all practitioners of Scalp Micro USA LLC are trained and approved in accordance with the company’s treatment protocols and are licensed and insured to perform Scalp Micropigmentation. If you are unable to attend your appointment, we require 48 hours notice in order to reallocate your appointment. Any cancellations or reschedules within 48 hours will result in a $250 rebooking fee + session payment in full to be placed back into the schedule. Please arrive for your treatment at least 15 minutes in advance so that the necessary paperwork can be completed. Late arrival may result in reduced treatment time or forfeiting of the appointment. Scalp Micro USA LLC will endeavor to ensure that your appointment runs to time, however, for reasons beyond our control, we may need to cancel or postpone your appointment at short notice. In this unlikely event, we will make every effort to contact you in advance. We do not offer compensation for postponed appointments. Prior to your appointment we will inform you of any preparation required in advance of your treatment. Deposits and Payments Scalp Micro USA may request a non-refundable deposit in order to secure your appointment. This deposit will be deducted from your treatment cost. Should you cancel or fail to arrive for your treatment, the non-refundable deposit will be used as a cancellation charge. Should you choose to change your appointment with 48 hours notice, the deposit will be allocated to the new appointment. Any cancellations or reschedules within 48 hours will result in a $250 rebooking fee + session payment in full to be placed back into the schedule. Payments- Scalp Micro USA will accept the following forms of payment: 1. Cash 2. Debit/Credit Cards (*3% additional fee is charged) 3. Certified Bank Check Payments can be staged over your amount of sessions, however 50% of your overall treatment quote is payable prior to commencement of your first treatment. The quotation provided during your consultation is valid for 1 year. Treatment Suitability We always assess whether treatment is suitable for your, or likely to be successful, prior to any treatment being carried out. If not, we will inform you of reasons why you are not a good candidate for treatment. Liability Scalp Micro USA LLC will not be liable in contract, tort, or otherwise for any economic loss (including, without limitation, loss of profit), or for any other special, indirect, or consequential loss or damage arising out of, or in connection with, its provisions of any goods and/or services to the client. It is the clients responsibility to ensure that he or she provide Scalp Micro USA LLC with all relevant medical details prior to each treatment. Scalp Micro USA LLC will not be liable for any damage that occurs as a result of the client’s failure to disclose such details. The client agrees to comply with all instructions and or recommendations given to them by, or on behalf of Scalp Micro USA LLC regarding the care of a treated area. Nothing in these terms of business shall exclude or limit Scalp Micro USA LLC liability for death or personal injury resulting from Scalp Micro USA LLC negligence. Scalp Micro USA Guarantee Scalp Micro USA provides a satisfaction guarantee against unforeseen fading and/or lightening of color. This guarantee lasts for 12 months (1 year) from the date of initial treatment. This guarantee is effective only after the client has completed his/her quotable number of sessions. (This is the number of sessions initially quoted for during the consultation). Any alterations to agreed style, including repositioning of hairline, increasing of density, darker color, and other fine tuning will not be covered under the guarantee and is chargeable and an additional fee. Should laser removal be necessary, the client will be responsible for the costs incurred. Acknowledgements I confirm that I have read and understood the information set out above and in the documents provided to me. In particular, I acknowledge that the SMP treatment is a permanent change to my appearance and that there is no guarantee that the markings can be changed or removed at a later date. I understand the efficiency of the SMP treatment varies from individual to individual and I understand that a very small portion of clients may fail to respond fully to the treatment and I, as an individual, may not respond. I understand that SMP treatment will require multiple sessions (minimum 2) due to the different skin type, hair tone, and some clients may require more than one course of treatment. I understand that some maintenance will also be required. I understand that the treatment I receive will be appropriate for my specific needs and will be performed by a certified and trained practitioner of Scalp Micro USA LLC. I understand following treatment the skin will be red and there can be a small amount of swelling which is normal. Blistering or crusting is not common but can occur and can take weeks to diminish. I understand that if this occurs, I will contact Scalp Micro USA LLC in the first instance. I will follow any instructions/recommendations given to me by Scalp Micro USA LLC regarding the care of the treated area prior to, during, and after treatment. After treatment, treated areas should not be picked, scratched, or traumatized and should be kept well moisturized as advised in the aftercare recommendations. I confirm I have advised a Scalp Micro USA LLC representative of (i) any skin condition that I have in the area of SMP treatment to be carried out (ii) any medical condition that I have or any medication that I am on, which may affect my suitability as a candidate for the SMP treatment. I will inform Scalp Micro USA LLC if am actively sun tanning. Scalp Micro USA LLC will not be held liable for any damage which results from my failure to adhere to aftercare guidelines. I confirm I have been given the opportunity to discuss the SMP treatment with the Scalp Micro USA LLC representative and I have had the opportunity to ask questions relating to this treatment. I confirm that I am over the age of eighteen and have provided proof of my age, if necessary. I confirm that the information I have provide to Scalp Micro USA LLC is true and accurate to the best of my knowledge. I understand that photographs of my face and scalp will be taken before, during, and after treatment and stored by Scalp Micro USA LLC for the purpose of providing me with SMP treatment and for its internal records. I understand that Scalp Micro USA LLC reserves the right to use these photos on, but not limited to the company’s social media channels, website, and marketing materials.

You agree and opt-in to receive SMS text messages from Scalp Micro USA. I consent to the storage and processing of my personal data (including any photographs) by Scalp Micro USA LLC for the purpose of providing me the SMP treatment. If you experience any concerns with your treatment, please contact Scalp Micro USA at 844-978-0098.