Consultation and Consent form

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Hello, and welcome to Derma Design. I'm Katy and I'll be doing your treatment. Firstly, I'd like to say a big thank you for chosing me to do your permanent make up.

This consultation form is the first step of the process.Its so important that I can meet your expectations and this can only be achieved if I have a good background information. Every client is completely unique and therefore results will be different depending on skin type, lifestyle, genetics and medication.

please answer these questions to the best of your knowledge and if you don't know, that's fine. Just say so. The details will be discussed prior to treatment and if you have questions, message me on 07539 553385. Xx

My website is always handy to get some inspiration. Www.DERMADESIGN.co.uk
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Name* This field is required.
First Name
Last Name
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Email
example@example.com
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Your Phone Number
Area Code
Phone Number
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In Case of Emergency Contact
First Name
Last Name
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Emergency Contact Phone Number
Area Code
Phone Number
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I absolutely understand micro pigmentation is process and not an exact science and that every client heals differently. I understand that this is an elective procedure that is not medically necessary and is a multi-treatment process.* This field is required.
Agreed
Other
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Area of micropigmentation* This field is required.
Eyebrow
Lip Blush
Lash Enhancement/ Eye liner
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To get the best results, preparation is very important. * This field is required.
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To get the best results, preparation is very important. The better your skin health, the better and more comfortable your procedure will be. Keep well hydrated with the right sort of fluids in the lead up to your appointment. Reduce your caffeine and alcohol intake and protect your skin from the sun before and after the procedure. * This field is required.
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To get the best results, preparation is very important. The better your skin health, the better and more comfortable your procedure will be. Keep well hydrated with the right sort of fluids in the lead up to your appointment. Reduce your caffeine and alcohol intake and protect your skin from the sun before and after the procedure.* This field is required.
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How would you describe your skin type?* This field is required.You may select more than one option as skin is rarely straightforward.
Normal
Dry
Oily
Combination
Very oily
Blemish prone
Hormonal
Sensitive
Don't know
Other
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Have you ever had semi permanent make up before?Even if it was several years ago. This would include microblading.
YESNO
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If yes, please tell me the history of it.Eg. Where it was, and how long ago and what does
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What would your ideal results of you treatment look like?Are there things you'd like to improve, eg symmetry, colour, size, balance fullness etc
For ideas of styles please look at my information pack or my website www.dermadesign.co.uk
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(OPTIONAL) it always helps to have an image on file of the area so I can plan for your treatment. This is desirable but non essential if you haven’t had treatment before. If you can't do it at this time, then please dont worry. If you have had semi permanent make up before, you definitely must send me a picture prior to treatment as I will need to see if correction work is required.
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The clinic is located to the rear of 81 Beacon Street. There is parking onsite, on the drive at the back of the property and next to the entrance. There is a ring doorbell next to the gate. If this doesn't connect then please just message/call me and i will come out to greet you.
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What will take place on the appointment day -

STEP 1: Consultation

When you come to the appointment, I will talk you through the treatment and discuss your medical history and suitability. I will look at your skin and discuss expectations. Your online consultation form and your patch test results will bee checked.

STEP 2: Choosing the shape and colour.

Then we will together discuss the possible shape and desired results against what is achievable. I will then draw, measure and map you eyebrow shape for you to approve. We'll discuss colour and you'll tell me the type of shade you are looking for once healed.

Once you are satisfied with the choice and have approved the shape, the procedure can start.

Paperwork will then be signed.

STEP 3: Lets start tattooing.

A first light "pass" over the design will happen. This may feel like plucking or a warm sensation depending on the procedure. After this, numbing will be applied so that the procedure remains comfortable.

STEP 4: Pigmentation

Pigment is then repeatedly implanted into the eyebrow. How long this takes depends on the skin quality. You may be asked to sit up and then back down so that I can check the balance and density.

STEP 5: Aftercare

This is the most important part. An aftercare pack and full written and verbal instructions will be given to you so that you can get the best results.

STEP 6: A touch up

After your eyebrows are healed, which usually takes around 6 weeks, you should have a follow-up appointment between 6 -12 weeks. I will make any adjustments required, add some extra hairstrokes or shading if parts have been lost with healing and define the final look of your eyebrows.
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The first appointment may take 2 - 3 hours. The required shape, colour and expected results will be discussed. It is very important that you are happy and confident in your decisions on style and shape. The shape will be measured pre drawn and its vital that you are happy with this prior to starting the treatment (N/A lash liner). I, the technician, have the right to refuse treatment if I feel the shape or the customers expectations are not suitable or achievable.
Agreed
Other
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I agree to pay full fee on my first treatment. I understand that pigment on healing will heal significantly lighter than when first applied. The fade could be 40% or more. This is something beyond the technicians control. For new full pmu procedures - the price includes two appointments, the first treatment and a follow up for top up treatment. If I don’t return within 12 weeks, the make up will fade faster in the skin and additional work will be charged for. The top up appointment is important and usually schedule for approximately 6 weeks after the first. Top up can not be done at an earlier point as the skin needs to heal and the pigment settle. I agree that if I decide not to return for additional treatments my procedure is deemed incomplete and that my monies will not be refunded to me. Some customers may require a third treatment to get the colour density they require. A third treatment is chargeable at £70.* This field is required.
Agreed
Other
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The top up appointment is important and usually schedule approximately 6 weeks after the first. Top up can not be done at an earlier point as the skin needs to heal and the pigment settle. I agree that if I decide not to return for additional treatments my procedure is deemed incomplete and that my monies will not be refunded to me.* This field is required.
Agreed
Other
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BOOKING & CANCELLATION POLICY - To avoid wasted diary space, thank you for understanding. * This field is required.Cancellation Policy
Agreed
Other
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Your results will be better if your skin is in good condition. It is best to prepare by drinking plenty of water for skin hydration, make sure that you reduce your alcohol consumption and stay out of the sun prior to your treatment. I can not work on sunburnt skin. Aspirin and ibuprofen must not be taken within 24hrs of treatment. Please do not consume alcohol within 24hrs of appointment as this may result in accelerated blood flow and skin sensitivity.
Agreed
Other
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I confirm will agree all colours and shape prior to any work commencing, and that the technician will keep a log of colours etc. I agree to before, drawn and after photographs being taken. These photographs will be stored on file.
Agreed
Other
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Derma Design specialises in the gentler side the permanent make up but can never guarantee pain free. I accept that after the treatment the direct area treated may show signs of swelling, redness and in rare cases bruising. I accept some discomfort. I am aware that, treatment during menstruation may make me more sensitive to pain.
Agreed
Other
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The technician cannot guarantee the longevity of colour in the skin after application as this varies from person to person. I fully understand that colours will stay visible in the skin for 1 to 5 years and in some cases indefinitely. The pigment can be placed into the skin but it is up to your body how much is retained. I conﬁrm and accept that lifestyle choices, medications and skin type may fade my pigment faster.
Agreed
Other
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After the appointment, you will received an aftercare kit with everything you need to enhance your results and promote good healing. Written aftercare advice will be given either on paper or electronically. It is very important that you follow the advice for the best healed results. I understand that not following aftercare advice may result with unsatisfactory results.
Agreed
Other
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* This field is required.
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* This field is required.
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Eye liner aftercare guidelines * This field is required.
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I conﬁrm I will strictly adhere to the aftercare instructions given to me and only apply aftercare products given to the treated area. I also accept that ejection of pigment is possible if aftercare instructions are not followed.
Agreed
Other
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All needles and machine parts used are individually wrapped, single use where possible & sterile. I accept that whilst in treatment room all universal precautions are taken but my risk of infection begins the moment I leave the clinic.
Agreed
Other
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Should I get an infection post treatment, I will immediately visit my GP and accept that this is possibly due to the fact that I do not live in sterile conditions. If I have any concerns, I will telephone /message my technician to discuss.
Agreed
Other
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Pigments are mainly composed of iron oxide, alcohol, glycerol and water. They have been used for many years and considered very safe. Reaction is incredibly rare but not unheard of. Pigment DOES NOT contain PPD which is found in hair colourants and henna which some people can be allergic to. Pigments are categorised as inks.
Agreed
Other
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Have you had micro pigmentation before, e.g. microblading etc
Yes
No
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If yes, what type and when?
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PATCH TEST

I always prefer to do a patch test but I will do treatment without one if you meet both of the following conditions.

1. That you have had previous semi permanent make up or a tattoo before and...

2. You do not have a history of allergic reaction to dyes, cosmetic products or anesethics.

If you meet these conditions, you must sign a patch test waiver.

For, other customers, I will send out a patch test through the post.

I always prefer to patch test, and theses will now be done at home by the customer. A patch test kit will be sent out the week before your appointment. These will need to be carried out 48 hours prior to treatment. If you react to the test, this will prohibit treatment and must be disclosed to the clinic. If you do not receive the patch test, please call the clinic on 07539 553385 so that i can get one to you in time for treatment.
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I understand that a skin test can determine if I will have a reaction within 24 hours to the products tested but is inconclusive regarding whether I will have an allergic reaction at a later time or date. This is called a secondary reaction.
Agreed
Other
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Do you require a patch test sending out?* This field is required.
yes
no
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PATCH TEST CONSENT I have decided to have an allergy test. I understand that I may have an allergic reaction to the micropigmentation products within 24 hours and that if I do, treatment will not take place.* This field is required.
Clear
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PATCH TEST WAIVER - I waive my option to an allergy test and I confirm that I will release the technician from any liability to an allergic reaction should I wish to proceed with a micropigmentation procedure.* This field is required.
Clear
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TITANIUM DIOXIDE DISCLOSURE - Titanium dioxide is present as an ingredient in many pigment colours in small traces but present in larger quantities in lighter formulations. This stays in the skin for a long time, even when you can no longer see the pigment anymore. It is important you know this as it can change colour with laser treatment eg. laser hair removal.
Agreed
Other
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If considering laser hair removal, I will inform the laser specialist that I have had micro pigmentation as laser can drastically change the colour of the treated area if in direct contact.
Agreed
Other
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I understand that if I have an MRI or CAT scan micro pigmentation may tingle in the treated area but this will not affect the treatment.
Agreed
Other
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PLEASE TICK ALL CONDITIIONS WHICH APPLY TO YOUR MEDICAL HISTORY* This field is required.
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Diabetes* This field is required.
Yes
No
Other
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If yes, it it well controlled?
Yes
No
Other
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Heart Condition* This field is required.
Yes
No
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If yes, it it well controlled?
Yes
No
Other
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Cancer* This field is required.
Yes
No
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If yes, please give details
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Allergies or any allergic reactions?* This field is required.
Yes
No
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Please give details.
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Are you currently under the care of a doctor or hospital specialist?* This field is required.
Yes
No
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Please give details.
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Please list any medication you are taking including painkillers and or antibiotics.* This field is required.please type NA or none if it doesnt apply
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Please give any additional information you feel may be relevant to treatment.
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I understand that any medications listed can have an impact on my treatment. Although exact affect is unknown, I understand that bleeding, bruising and longer healing times as well and poor retention is possible. I am happy to proceed.* This field is required.
Yes
No
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I accept full responsibility for any complications that may arise during or following the treatment as a direct result of failing to disclose relevant information regarding my health or current medications.
Clear
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CONSENT I hereby consent to the application of micro pigmentation. I have read and understand the points and risks detailed in this consent form.
Clear
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Date
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