Lash Farm - SPMU Consultation Form

  • Semi-Permanent Makeup

    Consultation Record

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    SPMU CONSULTATION RECORD

    Semi-Permanent Make Up, also known as Micropigmentation is a procedure that can only be performed by a trained and qualified specialist using approved equipment to implant coloured pigments into the skin using sterile needles. The treatment requires your full consent and medical history disclosure so that your consultant can confirm you are a suitable candidate for the proposed treatment.

    PLEASE READ CAREFULLY – PLEASE SIGN WHERE INDICATED, ONLY when you are happy to proceed. Ensure all points below have been discussed with your consultant and you understand and accept these terms.

    Terms of your treatment:

    • You have chosen a cosmetic procedure that is not medically necessary and results are not guaranteed.

    • SPMU is an art process, not an exact science - and cannot guarantee an exact colour result due to how colours can heal differently in all individuals. The selected colour will be darker immediately after treatment. This darker colour should exfoliate and lighten within 7-14 days after treatment. Lighter colours fade faster than darker colours, and all colours can change with time.

    • You will be required to return for a top up 5-7 weeks after the initial treatment which will deem your brows complete. I understand that sometimes a second touch up session is required to achieve the desired result at the normal top up charge.

    • Your consultant will use a treatment plan to record the colours, needles used and pre and post treatment photographs. This information will be held securely in your consultation record.

    • The skin type of every client is different and annual top ups are recommended. Please note that some clients will need another 6 week top up after the annual top up depending on how well the treatment has held.

    • After each treatment some swelling or redness may occur, in some cases there may be bruising.

    Throughout the treatment you may experience some discomfort, but your consultant will reassure you throughout and endeavor to make you feel comfortable.

    • Pigments used in Semi Permanent Make Up contain iron oxides which differ to the inks used in tattooing. Please note that iron oxides can leave an orange stain in the skin overtime.

    • It is essential that if you ever have an MRI or a CAT scan you should inform the radiologist that you have had micropigmentation. You may experience some tingling in the treated area but this will not hinder or affect anything.

    • You must adhere to aftercare instructions given to you after your treatment. This is very important and will ensure you aren’t vulnerable to infections after leaving the clinic. You must let the treated area heal properly. Avoid picking, plucking or knocking as this will hinder the healing process and could make the treatment appear uneven thus requiring further work.

    • Be aware that skin altering procedures such as plastic surgery, implants and injectables may alter the Semi Permanent Make Up look.

  • TO BE COMPLETED BY THE CLIENT:

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  • DATE OF BIRTH (DD/MM/YY):

  • Date
     - -
  • Today Treatment (Select One)
  • PATCH TEST / WAIVER: (Select)

  • CONSENT

    I understand that my consultant will be in direct contact with me in relation to the micro pigmentation treatment. This treatment involves the use of disposable needles and that all other equipment is sterilized before use, all surfaces involved in the process are protected and that gloves will be worn at all times by the consultant during the treatment.

    I hereby consent to receiving a micro pigmentation treatment. My consultant has explained the terms and conditions of the treatment and I have fully understood these. I hereby give written consent to the consultant who is a trained specialist, to carry out the treatment of my choice as requested by me on this consent and treatment agreement.

  • Date
     / /

  • I consent to photographs being taken BEFORE, DURING, and AFTER my procedure. I agree to these being stored with my case file and used for insurance and promotional purposes.

  • MEDICAL FORM

  • Date of Birth (dd/mm/yy)
     / /
  • Gender
  • Have you had this treatment before?

  • If YES please answer the following:

  • Where you happy with the result?

  • MEDICAL CONDITIONS

    Please answer YES or NO to the following questions. These details will then be discussed (in confidence) with your consultant.
  • Do you feel fit and well, and able to have this treatment done today?
  • Are you over the age of 18?
  • Are you currently pregnant or breastfeeding?
  • Are you under the influence of alcohol or drugs?
  • Do you have any allergies or have you experienced any allergic reactions to
  • Are you currently taking any medication? Please List:
  • Do you have or are you planning to have any injectable, fillers or chemical peels?
  • Do you have any imminent holiday plans?
  • Do you knowingly suffer from any infectious diseases?
  • Do you suffer from high or low blood pressure?
  • Do you have any respiratory problems?
  • Do you suffer from dizziness or fainting attacks?
  • Do you suffer from heart problems?
  • Do you suffer from hemophilia?
  • Do you suffer from skin problems? (i.e. eczema, psoriasis on or around the treatment area)
  • Do you suffer from keloid scarring?

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    If you suffer from any of the above it is important that you notify your consultant who can take the necessary precaution to ensure you receive the best treatment to avoid any risks to your health.

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    I understand the importance of my accurate and complete medical history. I understand that withholding any medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medical history that it is my responsibility to inform my consultant.

  • Date
     / /

  • A deposit is required to secure your appointment.

    Ombre/Powder Brow - Deposit : £75.00

  • The despot secures your appointment and will be deducted from the final charge. The deposit is non refundable. 

     

    Payment Of Deposit - Please make payment to:

    Account Number: 97392316

    Sort Code: 608371

    Account Name: Louise Geary

    NOTE: Ensure You Use You Name As Reference

     

    If you wish to pay Cash Deposit please advise Louise

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