GENERAL CONSENT & MEDICAL HEALTH FORM

Consent / Medical Form

First Name:

Last Name:

Date of birth:

Mobile Number:

Your email:

Address:

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).
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 understand 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 understand 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. 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?

Do you suffer from blood disorders or clotting issues?

Do you suffer from Abnormal Heart Condition?

Do you suffer from any of the following: Anaemia, Epilepsy, Seizures, Haemophilia?

Do you suffer from any of the following: Liver Disease, Kidney Disease, Hepatitis, HIV or AIDS?

Have you ever had a Stroke?

Do you suffer from Palpitations?

Do you suffer from High or Low Blood Pressure?

Do you suffer from Diabetes?

Do you suffer from Hormonal Changes?

Do you suffer from Thyroid Abnormalities?

Do you suffer from Tumours, Growths or Cysts?

Do you suffer from Alopecia?

Do you suffer from Trichotillomania?

Do you suffer from Hyperpigmentation?

Do you suffer from Psoriasis, Eczema, Dermatitis or other Skin Sensitivity?

Do you suffer from Hypertrophic or Keloid Scars?

Do you suffer from Protruding or Varicose Veins?

Do you Bruise or Bleed Easily?

Do you suffer from Prolonged Bleeding or Healing Problems?

Do you suffer from Cold Sores (Herpes Simplex)?

Do you suffer from Glaucoma?

Do you suffer from Dry Eyes or Watery Eyes?

Do you wear Contact Lenses?

Are you using any products to stimulate Lash growth?

Have you had Botox Injections? If yes, when was the last time?

Have you had Filler Injections? If yes, when was the last time?

Are you using skin care products that contain Retinol or Vitamin A?

Have you had Chemical or Laser Peel within the last 6 weeks?

Do you suffer from Sensitivity to Cosmetics?

Have you ever had a reaction to hair dye or lash tint?

Do you suffer from any allergies?

Do you have other Tattoos?

Do you smoke / vape?

Are you currently taking any antibiotics or medications?

Please provide details if you answered yes to any of the questions above:

I understand that I have the right to discontinue treatment at any time & I understand payment will still have to be made in full. PUBLICITY MATERIALS - I authorise the taking of clinical photographs and videos. I understand that photographs and video may be taken of me for educational and marketing purposes. I agree not to make slanderous or libellous comments against the business or technician if for any reason I am dissatisfied with the treatment outcome on any social media, public websites or press. I agree to allow the technician and business to interact directly with the business or through mediation to find a suitable resolution to any issues that I may have. I CERTIFY THAT I HAVE READ AND HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERED 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 CONSENT AND PROCEDURE PERMIT.

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

Consent / Medical Form

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