I CERTIFY THAT I HAVE READ, AND HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT EXPLANATIONS THEREIN REFERRED TO WERE MADE, AND I ACCEPT FULL RESPONSIBILITY FOR THESE AND OR OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE PERMANENT COSMETIC/TATTOO PROCEDURES WHICH IS TO BE PERFORMED AT MY REQUEST ACCORDING TO THIS COSENT AND PROCEDURE PERMIT.