PMU Client Consent & Medical History Form 2021

CONSENT & MEDICAL HISTORY CLIENT FORM
MOBILE 07714 568037 EMAIL theyvetteclinic@gmail.com

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TO BE FILLED IN BY THE CLIENT
Full Name
Title
Address
Post Code
Phone/ Mobile No.
Format: (000) 000-0000.
D.O.B

MonthDayYear
Date
Email
example@example.com
Occupation
Preferred method of contact
Preferred method of contact
TODAYS PROCEDURE -
I agree to photographs being taken, BEFORE, DURING and AFTER my procedure which will be kept in my case file, or used for promotional purposes.
PATCH TESTING FOR ALLERGIES

Patch Test/ Waiver (please tick A or B)
TITANIUM DIOXIDE:

Titanium Dioxide is a clear ingredient in our pigments and is not always visible in the skin, even though it may be present. Some cosmetic lasers will permanently alter the colour of titanium dioxide, therefore it is vital that you inform your laser specialist where your micro pigmentation procedure is. Your laser specialist will then take steps to ensure any adverse reactions.

NICKEL:

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
I have read and understood this section
PATCH TEST COMPLETED ON DATE

MonthDayYear
Date
Client Signature
SECTION 1
To comply with the Tattooing Act please tick YES or No to the following 4 boxes
Are you over 18 years of age?
Are you pregnant or breastfeeding?
Are you under the influence of alcohol or illegal drugs?
Do you feel fit, well and able for todays procedure?
If you are having Lip Blush today, you understand that if you have the HSV virus (that commonly causes cold sores), this procedure can trigger the bodies auto immune response. This treatment cannot give you a cold sore if you do not already have the virus. If you have suffered in the past from cold sores you have been advised to see your GP to obtain viral suppressants to take 5 days before treatment and 5 days after.
SECTION 2

Health related questions
Do any of the following apply? Please tick YES or NO to the questions in the boxes below, All answers will be treated in the strictest of confidence.
Do you have any allergies or have you experienced any allergic reactions to medicine products such as latex, plaster, nickel etc?
Do you have or are you having any injectables, fillers or chemical peels?
Do you have any imminent holiday plans?
Do you have any keloid scarring?
Do you suffer from epilepsy and have had a seizure in the last 2 years?
Do you suffer from haemophilia?
Do you knowingly have any infectious diseases?
Do you knowingly have Hepatitis C?
Do you suffer from shingles?
Do you suffer from cold sores, blisters or skin disorders in the area to be treated?
Do you have diabetes?
Do you have any respiratory problems?
Do you have any any problems with wounds healing?
Do you take any blood thinners or anti inflammatory?
Do you take Antabuse?
Do you take Roaccutane?
Do you have high or low blood pressure?
Do you wear contact lenses or suffer from Glaucoma?
Are you currently taking any medications?
Are you 5 weeks pre or post radiotherapy/chemotherapy treatment?
Are you allergic to any local anaesthetics?
if YES to any medications, please list here .....
TERMS OF YOUR TREATMENT
Please choose YES if you agree or NO if you disagree. Your specialist will check through and ensure that you understand and accept these terms.
I understand that micro pigmentation is a process with healing variables, therefore healed colour cannot be guaranteed. AGREED
I understand that SPMU or SMP is a multi treatment process with colour beingimplanted slowly and carefully over a period of time in a layering process. AGREED
My chosen colour will look much darker when initially implanted but should exfoliate and lighten within 7-28 days. AGREED
I understand that all colours will fade and alter with time. To keep a fresh appearance, a re-touch procedure will be required. Fade is dependent on age, skin, type, medication and colour chosen and sun exposure. AGREED
I agree that my specialist will use a treatment plan to 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. AGREED
I understand that after each treatment the treated area may swell, 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. AGREED
I understand that if I have a MRI or CAT scan I must tell the radiologist that I have had a SPMU or SMP procedure. I may experience a slight tingling in the treated area. AGREED
I have been given aftercare instructions and I understand that I must adhere strictly to these instructions. AGREED
I am aware that in any sun exposure, future skin altering procedures, such as plastic surgery, peels, implants, and/or injectables may alter the appearance of my procedure. AGREED
My technician has discussed the likely outcome with me and recommended treatment plan, prior to any work being agreed and undertaken. AGREED
I have had previous PMU work completed elsewhere, if yes I agree to completing The Yvette Clinics existing work risk and sign off form.
I have had previous PMU work completed elsewhere, if yes I agree to completing The Yvette Clinics existing work risk and sign off form.
IF YOU ANSWERED YES TO ANY PREVIOUS MEDICAL HISTORY QUESTIONS:
I understand my condition or medication may affect the treatment including bruising, bleeding and additional healing time. AGREED
I understand the importance of providing an accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure. AGREED
I understand that there are no guarantees as to the success or longevity of my treatment. AGREED
I accept these terms and hereby give my written consent for a trained specialist to carry out the course of treatment of my choice. AGREED
Client Signature here
DATE

MonthDayYear
Date
Technician Signature here
DATE

MonthDayYear
Date
Client to sign off pre-draw shape
I have approved the pre-draw shape before work begins
Client Pre-draw photos
Take Photo
Upload File
Technician to add clients BEFORE,AFTER, Healed at 6 weeks Photos here
BEFORE
Take Photo
Upload File
AFTER
Take Photo
Upload File
HEALED 6 WEEKS
Take Photo
Upload File
Client Signature for healed 6 weeks results
Should be Empty:

CONSENT & MEDICAL HISTORY CLIENT FORM

TO BE FILLED IN BY THE CLIENT

PATCH TESTING FOR ALLERGIES

SECTION 1

SECTION 2

TERMS OF YOUR TREATMENT

IF YOU ANSWERED YES TO ANY PREVIOUS MEDICAL HISTORY QUESTIONS:

Client to sign off pre-draw shape

Client Pre-draw photos

Technician to add clients BEFORE,AFTER, Healed at 6 weeks Photos here

BEFORE

AFTER

HEALED 6 WEEKS