Treatment Form

1

Full Name* This field is required.

First Name

Last Name

2

Address* This field is required.

Street Address

Street Address Line 2

Town/ City

County

Postcode

Country

3

Contact Number* This field is required.

4

Date of Birth* This field is required.

5

E-mail* This field is required.

6

Preferred method of contact* This field is required.

7

Are you over 18 years of age?* This field is required.

YESNO

8

Are you pregnant or breastfeeding?* This field is required.

YESNO

9

Are you / will you be under the influence of alcohol or illegal drugs at the time of your procedure?* This field is required.

YESNO

10

Do you feel fit and well and able to have a cosmetic tattooing procedure done?* This field is required.

YESNO

11

I agree to photographs being taken BEFORE, DURING and AFTER my procedure which will be kept in my case file, or used only with my written consent for promotional purposes.* This field is required.

YESNO

12

Do you have any allergies or have you experienced an allergic reaction to medicine or products (such as latex, plaster, nickel etc)?* This field is required.

YESNO

13

Do you have or are you having injectables, fillers or chemical peels?* This field is required.

YESNO

14

Do you have any imminent holiday plans?* This field is required.

YESNO

15

Do you have any keloid scarring?* This field is required.

YESNO

16

Do you suffer from epilepsy and have had a seizure in the last 2 years?* This field is required.

YESNO

17

Do you suffer from Haemophilia?* This field is required.

YESNO

18

Do you knowingly have any infectious diseases?* This field is required.

YESNO

19

Do you knowingly have Hepatitis C?* This field is required.

YESNO

20

Do you suffer from shingles?* This field is required.

YESNO

21

Do you suffer from cold sores, fever blisters or skin disorders in the area to be treated?* This field is required.

YESNO

22

Do you have diabetes?* This field is required.

YESNO

23

Do you have any respiratory problems?* This field is required.

YESNO

24

Do you suffer from or have any problems with wounds healing?* This field is required.

YESNO

25

Do you take bloody thinners or anti- inflammatories?* This field is required.

YESNO

26

Do you take Antabuse?* This field is required.

YESNO

27

Do you take Roaccutane?* This field is required.

YESNO

28

Do you have high or low blood pressure?* This field is required.

YESNO

29

Do you wear contact lenses or suffer from glaucoma?* This field is required.

YESNO

30

Are you currently taking any medication?* This field is required.

YESNO

31

Are you 5 weeks pre or post radiotherapy/ chemotherapy treatment?* This field is required.

YESNO

32

Are you allergic to any local anaesthetics? * This field is required.

YESNO

33

I understand that Semi Permanent Make up is a process with healing variables, therefore healed colour cannot be guaranteed.* This field is required.

YESNO

34

I understand that Semi Permanent Make Up is a multi treatment process with colour being implanted slowly and carefully over a period of time using a layering technique.* This field is required.

YESNO

35

My chosen colour will look much darker when initially implanted but should exfoliate and lighten within 7 - 14 days.* This field is required.

YESNO

36

I understand that additional work cannot be undertaken for 4 - 8 weeks in order to allow the skin to fully heal.* This field is required.

YESNO

37

I understand that all colours will fade and alter with time. To keep a fresh appearance a re- touch procedure will be required every 12- 18 months. Fade is dependent on age, skin type, medication, colour chosen and sun exposure. * This field is required.

YESNO

38

I agree that my specialist will document a treatment plan and keep a log of the colours we have chosen, along with my pre and post treatment photographs. This information will be held securely in my confidential file.* This field is required.

YESNO

39

I understand that my specialist will discuss likely outcomes with me and recommend a treatment plan prior to any work being agreed and undertaken.* This field is required.

YESNO

40

I understand that after each treatment the treated area may swell or show redness and in some cases bruising. My specialist will recommend how to take care of this. I may experience some discomfort but my specialist will reassure me throughout and will endeavour to make me feel comfortable. * This field is required.

YESNO

41

I understand that if i have an MRI or CAT scan i must tell the radiologist that i have had a Semi Permanent Make Up procedure. I may experience a slight tingle in the treated area. * This field is required.

YESNO

42

I am aware that full aftercare instructions will be provided to me after my treatment and i understand that i must adhere strictly to these instructions.* This field is required.

YESNO

43

I am aware that sun exposure, future skin altering procedures, such as plastic surgery, peels, implants, and/ or injectables may alter the appearance of my Semi Permanent Make Up. * This field is required.

YESNO

44

I understand that that permanent cosmetics / medical enhancement is an advanced form of tattooing.* This field is required.

YESNO

45

I am aware that a sensitivity reaction to anaesthetics can occur and accept all responsibility if allergic response occurs. * This field is required.

YESNO

46

I fully understand and accept that non - toxic pigments are being used during the procedure and that cosmetic enhancement achieved may fade over the course of 1 - 3 years. Even though the colour may fade the pigment will remain in the skin indefinitely and may leave a light residue of colour. * This field is required.

YESNO

47

I understand that my pigment might migrate under the skin, however this is a rare occurrence. * This field is required.

YESNO

48

I understand that loss of any eyelashes during the course of healing from Semi Permanent cosmetic eye enhancements will result in new eyelash growth over a 4 month period and that eyelash loss is rare and minimal.* This field is required.

YESNO

49

I understand that immediately after the procedure the enhancement can be 30% to 50% darker than the desired result and can take up to 10 days to lighten. * This field is required.

YESNO

50

I understand that the true colour will be visible 4 weeks after each application and that the colour may vary according to skin tones, skin type, age and skin conditions. I appreciate that some skins accept colour more readily than others and no guarantee of an exact effect or colour can be given. * This field is required.

YESNO

51

I understand that infection and possible scarring can occur if i do not adhere to the aftercare guidelines provided by my specialist. * This field is required.

YESNO

52

I understand that if i do not allow the specialist to complete the procedure then i'm accepting all responsibility for the result.* This field is required.

YESNO

53

I have undergone / been offered an allergy test prior to my initial treatment and therefore release my specialist from any liability related to any allergic reaction to applied pigments or other products used after the procedure or at a later date.* This field is required.

YESNO

54

TITANIUM DIOXIDE is a clear ingredient in our pigments and is not always visible in the skin, even though it may be present. * This field is required.

YESNO

55

I understand there are traces of nickel in some needles and pigments. This may affect me if i have an allergy to nickel. (In this case a patch test is strongly recommended.)* This field is required.

YESNO

56

Signature* This field is required.I have read and understood this section

Clear

57

I understand the importance of providing accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure.* This field is required.

YESNO

58

I understand there are no guarantees as to the success and longevity of my treatment. * This field is required.

YESNO

59

I accept these terms and hereby give my written consent for my trained specialist to carry out the course of treatment of my choice.* This field is required.

YESNO

60

Signature* This field is required.I certify that i have read and i have had explained to me, and fully understand to above consent form and that i have requested to have permanent cosmetic enhancement of my own free will.

Clear

61

Date* This field is required.

Date