luxpmudevon
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This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of semi-permanent makeup (SPMU). It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment. The SPMU procedure requires 2 visits (in some cases more may be required). Scheduled appointments for the touch up procedure require 48 hours’ notice for cancellation or rescheduling and are included in the original price ONLY when performed within 12 weeks after the original procedure. Outside 12 weeks or if scheduled appointments are missed, an additional charge will be incurred. 1. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years. Even once the colour fades, pigment itself may stay in the skin indefinitely. I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary per skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact colour can be given. I understand the actual colour of the pigment may be modified slightly, due to the tone and colour of my skin. 2. I have been informed that the highest standards of hygiene are met, and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit. 3. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care. 4. Common complications and risks include: Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed. 5. Uncommon complications and risks include: Skin infection (cellulitis) which can present as hot, red, shiny skin, there may be pus and you may also feel generally unwell. Infection is uncommon especially if you follow the aftercare advice. In the event of infection, you must see your doctor as soon as possible. Lip blush tattoos are likely to trigger the reactivation of cold sores (herpes simplex virus infection). Zovirax or alternative medication must be taken prior and after the procedure to prevent the outburst of cold sores. For eyeliner SPMU procedure there is a rare risk of eye injury which may include corneal abrasions or corneal scarring (which may lead to visual impairment). Eye infection or inflammation is also possible. In the event of any eye complications, you must seek urgent medical attention. migration of the pigment can occur, under rare circumstances, requiring excision and/or correction of the migrated pigment. 6. Some people may faint or feel faint with needles, if you feel unwell during treatment you must inform your practitioner as soon as possible. You must also inform your doctor or radiologist if you require an MRI scan following microblading as problems can occur with tattooed skin during the scan. 7. To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done now. 8. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure. I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. 9. I request the semi-permanent skin pigmentation procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences of the said procedure. There is a possibility of an allergic reaction to numbing agents and/or pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. I consent or waive the patch test. If waived, I release the technician from liability if I develop an allergic reaction to the pigment. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my SPMU procedure. I acknowledge some of these potential adverse changes may not be correctable. 10. I understand that this is an ‘elective’ procedure and that payment is my responsibility and is expected at the time of treatment. I fully understand this is a tattoo process and therefore not an exact science but an art.
Are you pregnant / breastfeeding? NoYes
Are you taking any medications that affect your body from healing? (blood thinners) NoYes
Do you suffer from Abnormal Heart Condition? NoYes
Do you suffer from Anaemia? NoYes
Do you suffer from Epilepsy? NoYes
Do you suffer from Haemophilia? NoYes
Do you suffer from Heart Murmur? NoYes
Do you have a Pacemaker? NoYes
Do you suffer from Trichotillomania? NoYes
Have you ever had a Stroke? NoYes
Do you suffer from Mitral Valve Prolapse? NoYes
Do you have Liver Disease? NoYes
Do you have Kidney Disease? NoYes
Do you have Hepatitis? NoYes
Do you have HIV or AIDS? NoYes
Do you have Circulatory Problems? NoYes
Do you suffer from Stomach Ulcers? NoYes
Do you suffer from Rheumatic Fever? NoYes
Do you suffer from Alopecia? NoYes
Do you suffer from Diabetes? NoYes
Do you suffer from High Blood Pressure? NoYes
Do you suffer from low Blood Pressure? NoYes
Do you suffer from Hormonal Changes? NoYes
Do you suffer from Palpitations? NoYes
Do you suffer from Tumours, Growths or Cysts? NoYes
Do you suffer from Thyroid Abnormalities? NoYes
Do you suffer from Hyperpigmentation? NoYes
Do you suffer from Psoriasis? NoYes
Do you suffer from Dermatitis or other Skin Sensitivity? NoYes
Do you suffer from Hypertrophic or Keloid Scars? NoYes
Do you Scar Easily? NoYes
Do you suffer from Protruding or Varicose Veins? NoYes
Do you Bruise or Bleed Easily? NoYes
Do you suffer from Prolonged Bleeding? NoYes
Do you suffer from Healing Problems? NoYes
Do you suffer from Cold Sores (Herpes Simplex) (applicable to lip treatments only)? NoYes
Do you have Blurred Vision? NoYes
Do you have Glaucoma? NoYes
Do you suffer from Dry Eyes? NoYes
Do you suffer from Watery Eyes? NoYes
Do you wear Contact Lenses? NoYes
Do you have other Tattoos? NoYes
Have you had Fat Transfer Injections? NoYes
Have you had Botox Injections? NoYes
Have you had Collagen Injections? NoYes
Have you used Accutane within the last 6 months? NoYes
Have you had Cortisone within the last 6 months? NoYes
Have you had Chemical or Laser Peel within the last 6 weeks? NoYes
Do you use any creams that contain Retinol? NoYes
Do you suffer from Sensitivity to Cosmetics? NoYes
Have you ever had a reaction to hair dye or lash tint? NoYes
Please provide details if you answered yes to any of the questions above:
By signing this document I confirm that I have read and understood the above consent form and provided true and accurate medical information to my best ability
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