Consent agreement for semi-permanent makeup Consent agreement for semi-permanent makeup This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetics application. If you have questions, please don‘t hesitate to ask. Micro pigmentation is a process of inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sealed and sterilised, and are disposed of after use. Cross contamination guidelines are strictly adhered to. Generally, the results are very good. However, a perfect result is not a realistic expectation. A retouch up after the healing process may be needed as stated in your consultation. Initially the colour will appear much more defined or darker compared to the healed result. Usually within 5 to 7 days the colour will fade 10-50%, soften and look more natural. The pigment is permanent but will fade over time and a colour boosts will be needed over 12 to 18 months depend on your skin and how you protected them from the elements. Date (DD/MM/YYYY) * Date of Birth (DD/MM/YYYY) * Full Name * Address * City * Phone * Postcode * Email * Emergency Contact’s Name * Emergency Contact’s Phone * Possible risks, hazards or complications Pain: There can be pain even after the topical anaesthetic has been used. Anaesthetics work better on some people than others. Infection: Infection is very unusual. The areas treated must be kept clean and not touch with dirty hands. See “After Care” sheet for instructions on care. Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. This is the purpose of your retouch. Asymmetry: Every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness. Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-‐5 days. Some people don’t bruise or swell at all. Anaesthesia: Topical anaesthetics are used to numb the area to be tattooed. LMX and zylocaine are used please inform your technician if you are allergic. MRI: Because pigments used in permanent cosmetic procedures contain iron oxides, you will need to inform your GP if you are planning to have a MRI. Allergic Reaction: Although allergic reactions ae very rare in permanent cosmetics a patch test is not a guarantee that you will not have an allergic reaction. A patch test must be perform 48 hrs prior to your procedure taking place. The alternative to these possibilities is to use cosmetics and not undergo the Permanent Cosmetics procedure. Consent and release for procedures performed: PATCH TEST A Patch Test must be performed 48 hours before treatment Has a patch test been performed? * Yes No Statement of consent – please read and check all lines * Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions I will call or email you. I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur. I understand that Retin A, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the colour. I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI. I accept full responsibility for the colour, shape, and positioning of the brow for the procedure done today. I understand that the implanted pigment colour can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the colour with future applications. I acknowledge that the proposed procedure involve risks and have possibilities of complications during and/or following the procedures such as: infection, poor colour retention. I have been quoted the cost of today’s appointment which includes one (1) retouch to be taken within 3mths of the initial procedure. After 3mths a fee will apply. I certify that I have read or have had read the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize Sue Folland as my permanent cosmetics technician to perform semi-permanent makeup procedures. What’s normal? Swelling, itching, scabbing, light bruising and dry tightness. Ice packs are a nice relief for swelling and bruising. Too dark and slightly uneven appearance. After 2-7 days the darkness will fade and once swelling subsides unevenness usually disappears. Any adjustments will be made during your retouch appointment. Colour change or colour loss. As the procedure area heals the colour will soften and lighten and sometimes seem to disappear. This is the purpose of the retouch appointment and is why the retouch is necessary. The procedure area has to be completely healed before a retouch can be performed. This takes at least four weeks. Needing a colour boost later. A touch up may be needed 1 to 3 years after the initial procedure depending on your skin type medications and sun exposure and life style. We recommend a retouch up 30 days after the first session (included in today’s price) and every few years to keep them looking fresh and beautiful. Failure to follow after care instructions may result in infections, pigment loss or discoloration. I have read, understand and agree to the above information. * Yes Medical questionaire: Please tick any of the following below that apply to you. I understand that it is important to answer each of the questions honestly and not withhold any information as failure to do so will increase the risk of infection, bleeding, poor healing, scarring and compromising the end results. I also understand that it is my responsibility to update any changes in medical history to Sue Folland before every treatment available. Please tick any of the following which apply to you: Acne/Accutane Allergies Alopecia Autoimmune Disease Blisters Breastfeeding Cancer Covid 19 Diabetes Eczema Epilepsy Fainting Episodes Fever Glaucoma Haemophilia Herpes Simplex/Cold Sores Hepatisis Heart Condition High Blood Pressure High Tempurature HIV Positive Infectious Disease Issues With Wound Healing Keloid Scarring Organ Transplant Pregnant Skin Disease Steroid Taking Medication Thyroid Tumours, Growths or Cysts Undergoing Chemotherapy Undergoing Radiotherapy Lip procedures only I have been informed by Sue Folland that lip blushing procedure can bring out the herpes simplex virus/cold sores on lips, even if I haven’t had an outbreak for years. Please choose one of the options below No, I do not or have never suffered from herpes simplex virus/cold sores Yes, I do suffer from herpes simplex virus/cold sores, and have taken anti-viral medication to try and prevent an outbreak. However, preventing an outbreak cannot always be guaranteed. If you have, or have previous had, cancer, please enter the last year you had it If you have had chemical peel, please enter the last year you had treatment for it If you are taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin, please list them below If you are allergic to anything, please list them below Please list any diseases or disorders not listed above Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl? Yes No Please list medication or vitamins you’re presently taking below I agree that all the above information is true and accurate to the best of my knowledge. * Yes Sensitivity Patch Test The sensitivity patch test must be completed in no less than 24hrs before a procedure. If you do not comply with these instructions your appointment will be rescheduled or cancelled. Please read these instructions and perform the patch test. If you experience a reaction please contact your technician immediately. If everything is ok with your patch test, please confirm below. 1. Place the pigment sample on one on the plasters provided in the envelope. (If the pigment is dehydrated, add a drop of water) 2. Place the topical anaesthetic on the other plaster. 3. Position each plaster on the following area; Behind each ear On top of the arm On the thigh On the buttocks Do not place in the crease of the elbow or knee 4. After 24 hours remove the plaster and exam in the skin. If there is no reaction i.e. no swelling redness itching irritation then it is safe to procedure with the treatment. 5. Should you experience any of the symptoms mentioned please remove the plaster and flush the area with cold water immediately. I have read and fully understand the above information. I have completed the sensitivity patch test as instructed and I have experienced NO Reaction. * Yes Photography Release Consent Enhance will take “Before” and “After” photos that will be kept on file, these will be stored along with your personal information safely under GDPR (May 25th 2018). We would like your permission to use these photos for advertising. For example, in portfolios, online and in advertisement, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising. Your consent * YES, feel free to use them NO, please do not use them Special requests, concerns or remarks for technician (optional) Thank you for completing the above information. Please now enter your name and today’s date below and submit the form. Signature (type your name) * Date (DD/MM/YYYY) * If you are human, leave this field blank. Submit
