Permanent Makeup Treatment Consent form

Permanent Makeup Treatment Consent Form

Please ensure you have completed the Consent Form at least 48 hours prior to your treatment appointment. Failure to do so may result in your appointment being postponed and the loss of your deposit. If you have any concerns in the meantime please contact us on 07765245406 or info@justbrowsinc.com
Personal Information
Name*

First NameLast Name
Email*
example@example.com
Date of birth*

DayMonthYear
Date
Mobile Number*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Please select which treatment you are having (you can select more than one option if need be):*

EyebrowsEyelinerLipblushAreola
Please read & check each line to confirm you agree with the following statements:*

I certify that I am over the age of 18.I am not under the continued influence of drugs or alcohol. Caffeine must be avoided 12 hours prior to the procedure. Alcohol must be avoided 24 hours prior to the procedure.I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and/or bruising may occur.I am not pregnant or nursing.I consent to receiving the procedure. The general nature of the treatment to be performed has been explained to me.I understand that Retin A, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the colour.I understand that sun, tanning beds, pools, some skin care products and medications can affect my final microblading result.I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I'm scheduled for an MRI (Magnetic Resonance Imaging).I understand that implanted pigment colour can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the colour with future applications and a touch up session within 6-8 weeks of initial procedure.Aftercare instructions have been explained to me which I will follow to the best of my ability.There will be no refunds for this elective procedure(s).
Client Medical Health Form

Do you suffer from any of the following conditions or take any of the following medications?
Please select all that apply:*

1. Hemophilia2. Diabetes mellitus3. Hepatitis A, B, C, D, E, F4. HIV5. Skin diseases6. Eczema7. Allergies8. Autoimmune diseases9. Herpes10. Infectious diseases/high temperature11. Epilepsy12. Cardiovascular problems13. Do you take blood thinners (anti-coagulants)?14. Are you pregnant?15. Do you take medications on a daily basis?16. Do you have a pacemaker fitted?17. Do you have a problem with wound healing?18. Have you consumed narcotics or alcohol in the past 24 hours?19. Have you had surgery, laser therapy or any other medical intervention in the past 14 days?NONE APPLY
Further Information:
If you answered "Yes' to some of the questions, it does not automatically mean that you are not a suitable candidate for treatment. Collecting data is of great significance to us because each client is a different individual thus an individual approach is required. The information you provide could also help in determining whether consultation with your doctor prior to the treatment is necessary or not. If you suffer from a disease/condition that is not mentioned in the table, please inform us below:
Photography & Video Release Consent

Our insurance company requires 'before' and 'after' photos/videos to be taken and kept on file. We would like your permission to use these photos/videos for advertising purposes. Your consent is necessary regarding this. Please note this consent is always implied with 'Pay With Smile' and all modelling appointments. We also use photography as measuring tool.
Please select option below to indicate your preference.*

YesNo
Explanation

The client is informed in detail by the Artist on the specific risks which may arise from the microblading treatment. The following risks are particularly explained to me as a client:
Please check ALL boxes to confirm understanding:*

Regardless of the staff's expertise and all safety precautions, an injury may occur during the treatment. Despite using the latest and best pigments, an allergic reaction is possible, but rare. The client is aware of that and bears responsibility.During and after the treatment, a temporary swelling, redness and/or itching may appear. Our experience tells us that these symptoms are transient in character. Depending on the skin structure, after the first procedure small scabs can occur followed by a loss of drawn strokes and change in colour intensity.During the first seven days the pigment is darker/brighter up to 40% and thicker 10-15%. Colour, i.e. colour reflection, depends on the natural pigment of the skin. Shape is determined according to face proportions. Symmetry is determined digitally while the clients eyes are closed due to negative influence of mimetics.Quality of the skin is different in clients, the skin differently reacts to pigment insertion, hence there is no guarantee for treatment success.Depending on the skin structure, it should be known that change in colour intensity is possible and that one or more re-touch appointments will be required.How long the pigment will last, minimum or maximum duration, cannot be precisely be determined, nor can a guarantee on the performed treatment be made.First touch-up is done 6-8 weeks after the procedure. Oily skin may require more refreshments.Permanent make-up always leads to skin injury. It is thus important to carefully and gently nourish the skin after the treatment to ensure healing without complications.Inadequate after care during the healing period may lead to poor results and the Artist does not bear responsibility for that.
Aftercare Agreement

For after-care, use exclusively the given products. Please do not use creams other than the given ones in order to prevent possible infections or allergic reactions. During the first two weeks after the procedure avoid public baths, suntanning, tanning beds, saunas, cosmetic treatments and intense workouts accompanied by sweating (sport activities) and contact with dust.
Please select ALL OPTIONS to confirm your understanding of the following:*

I confirm that I have read and understood the aforementioned information.I received clear and comprehensible answers to all the questions I asked.The procedure and the post-treatment care have been explained to me in detail and I agree to follow the instructions as per the treatment specific printed instructions provided to me.I did not get unrealistic guarantees regarding the expected results or the consequences of the said treatment.By signing the consent, I certify that I had a chance to ask about everything related to the implementation of treatment and that the Artist provided me with clear and comprehensible answers to all my questions.I have no other questions or objections.I confirm that I have had a patch test prior to my appointment with no adverse reactions.
Consent
I certify that I have read and fully understand the contents of this consent form.

I understand the risks and alternatives involved in the procedure(s) I have had the opportunity to ask questions, and all of my questions have been answered.

I authorise Sarah Jane Sivyer as my permanent makeup artist to perform on my body the procedure outlined above today.

I CONFIRM THAT I HAVE READ AND UNDERSTAND THIS CONSENT FORM AND I AGREE TO BE BOUND BY IT. I AGREE THAT ALL THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Signature*

Clear
Date of Signature *

DayMonthYear
Date
I prefer to be contacted:

EmailPhoneText
Should be Empty:

Permanent Makeup Treatment Consent Form

Personal Information

Client Medical Health Form

Photography & Video Release Consent

Explanation

Aftercare Agreement

Consent