Microneedling & Plasma Consent Form

Microneedling & Plasma Consent Form

Please ensure that 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.
If you have any concerns in the meantime please contact us on +44 7765 245406.

The client has been informed about the facial skin treatment using the Philings technique. The nature of the procedure, it's purpose and benefits, duration and expected result, possible risks, painful and other temporary or permanent consequences have been explained to the client in detail.

Just Brows Inc. Ltd is obligated to perform the treatment in strict compliance with all hygiene and health protection measures. In order to perform the facial skin treatment in a safe manner, please answer the following health questions truthfully. This information is confidential and it shall also be handled in that way. It will not be shared with any third party.
Name
Name

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

DayMonthYear
Date
Address
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Phone number

Area CodePhone Number
Mobile number
Format: 00000000000.
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:
If your response to any of the before mentioned questions was 'Yes', please write down a detailed explanation.
If you answered "Yes' to some of the questions above, 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:
I consent to photography, filming, recording and/or digital imaging of the treatment to be performed and usage of the images for advertising purposes.
Explanation

The client is informed in detail by the technician on the specific risks which may arise from the Philings treatment. The following risks are particularly explained to me as a client.
Please check ALL boxes to confirm understanding:
Micro-needling - Specific Risks

The client is informed in detail by the technician on the specific risks which may arise from the Philings treatment. The following risks are particularly explained to me as a client.
Please check ALL boxes to confirm understanding:
Phi-Ion (Plasma Treatment) - Specific Risks

The client is informed in detail by the technician on the specific risks which may arise from the Philingstreatment. The following risks are particularly explained to me as a client.
Please check ALL boxes to confirm understanding:
Binding Form
Please check ALL boxes to confirm understanding:
Consent

I certify that I have read and fully understand the contents of this microblading consent. 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 Eyebrow Microblading Artist to perform on my body the Eyebrow Microblading procedure desired 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
Date of Signature:

DayMonthYear
Date
I prefer to be contacted:
Should be Empty:

Microneedling & Plasma Consent Form

Client Medical Health Form

Explanation

Micro-needling - Specific Risks

Phi-Ion (Plasma Treatment) - Specific Risks

Binding Form

Consent