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

MrMissMsMrs
Address
Post Code
Phone/ Mobile No.
D.O.B

MonthDayYear
Date
Email
example@example.com
Occupation
Preferred method of contact

EmailTextPhone
Preferred method of contact

Yes I am happy for The Yvette Clinic to keep in touch via email, text or post with exciting offers and newsletters
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.

YesNo
PATCH TESTING FOR ALLERGIES

Patch Test/ Waiver (please tick A or B)
(A) I understand that a skin test can determine within 24 hours if I will have a reaction to the products, but that it is inconclusive regarding whether I will have an allergic reaction at any time in the future. I choose to waiver my option to an allergy test and wish to proceed with the treatment.(B) I have undergone/been offered an allergy test prior to my initial treatment and there by release the technician from any liability related to any allergic reaction to applied pigments or other products used during, after theprocedure or at a later date.
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

YesNo
PATCH TEST COMPLETED ON DATE

MonthDayYear
Date
Client Signature

Clear
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?

YesNo
Are you pregnant or breastfeeding?

YesNo
Are you under the influence of alcohol or illegal drugs?

YesNo
Do you feel fit, well and able for todays procedure?

YesNo
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.

YesNo
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?

YesNo
Do you have or are you having any injectables, fillers or chemical peels?

YesNo
Do you have any imminent holiday plans?

YesNo
Do you have any keloid scarring?

YesNo
Do you suffer from epilepsy and have had a seizure in the last 2 years?

YesNo
Do you suffer from haemophilia?

YesNo
Do you knowingly have any infectious diseases?

YesNo
Do you knowingly have Hepatitis C?

YesNo
Do you suffer from shingles?

YesNo
Do you suffer from cold sores, blisters or skin disorders in the area to be treated?

YesNo
Do you have diabetes?

YesNo
Do you have any respiratory problems?

YesNo
Do you have any any problems with wounds healing?

YesNo
Do you take any blood thinners or anti inflammatory?

YesNo
Do you take Antabuse?

YesNo
Do you take Roaccutane?

YesNo
Do you have high or low blood pressure?

YesNo
Do you wear contact lenses or suffer from Glaucoma?

YesNo
Are you currently taking any medications?

YesNo
Are you 5 weeks pre or post radiotherapy/chemotherapy treatment?

YesNo
Are you allergic to any local anaesthetics?

YesNo
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

YesNo
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

YesNo
My chosen colour will look much darker when initially implanted but should exfoliate and lighten within 7-28 days. AGREED

YesNo
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

YesNo
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

YesNo
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

YesNo
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

YesNo
I have been given aftercare instructions and I understand that I must adhere strictly to these instructions. AGREED

YesNo
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

YesNo
My technician has discussed the likely outcome with me and recommended treatment plan, prior to any work being agreed and undertaken. AGREED

YesNo
I have had previous PMU work completed elsewhere, if yes I agree to completing The Yvette Clinics existing work risk and sign off form.

YesNo
I have had previous PMU work completed elsewhere, if yes I agree to completing The Yvette Clinics existing work risk and sign off form.

YesNo
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

YesNo
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

YesNo
I understand that there are no guarantees as to the success or longevity of my treatment. AGREED

YesNo
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

YesNo
Client Signature here

Clear
DATE

MonthDayYear
Date
Technician Signature here

Clear
DATE

MonthDayYear
Date
Client to sign off pre-draw shape
I have approved the pre-draw shape before work begins

Clear
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

Clear
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