Client Patch Test Consultation Form

  • Advised Consent Form for Semi-Permanent Cosmetic Procedure

    This form is required if a patch test is being carried out by Lashour, for a client who has never had Ombre Brows before. This form must be complete prior to the appointment.

  • I hereby authorise   *   to perform upon myself a permanent cosmetic/medical enhancement. If any unforeseen condition arises in the course of the procedure(s) I further request and authorise her to use her full judgment and do whatever she deems advisable and necessary in the circumstances.

  • I understand that permanent cosmetic/medical enhancement is an advanced form of tattooing.
    I accept responsibility for determining the shape and position of the enhancement as agreed during the course of my consultation.

    I am aware that allergic responses to pigment is rare and accept all responsibility if allergic response occurs.
    I am aware that a sensitivity reaction to anaesthetics can occur and accept all responsibility if allergic response occurs.


    I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over the course of 1-3 years. Even though the colour has faded, the pigment will stay in the skin indefinitely and may leave a light residue of colour. I understand that permanent make up can leave the micro scars.


    I understand and accept that each procedure is a process which may require multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I need to return for a retouch.


    I understand that the retouch procedure, if required, will be performed 6-12 weeks after the initial procedure and that I will be charged an additional fee for this. I understand that a retouch procedure takes place 6-12 weeks after the initial application to allow the procedure site to fully heal. I understand that it is my responsibility to book the appointment when it is convenient for both parties.


    I am aware that the result of the procedure is determined by the following:
    Medication. Skin Characteristics - i.e. dry/oily/sun-damaged. Natural skin undertones. Alcohol intake and smoking. A compromised immune system. Post procedure care treatment. Usage of harsh chemicals on brow area, i.e. AHAs or bleaching & lightening products.

     

    I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-4 days dependent on lifestyle. In some cases bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, any exercises and exposure to the sun should be stopped for up to two weeks following the treatment.


    I understand that immediately after the procedure the enhancement can be 30 to 50% darker than the desired result and can take between 4-10 days to lighten. I understand that the true colour will be visible 1 month after each application, and that the colour may vary according to skin tones, skin type, age and skin conditions. I appreciate that some skins accept colour more readily than others and no guarantee of an exact effect or colour can be given.


    I understand that if I do not allow the technician to complete the procedure, I accept all responsibilities for the result.
    For the purpose of documentation, I also consent to the taking of "before" and "after" photographs or videos of said procedure(s).


    I absolutely understand that micropigmentation is an art process, and is not an exact science and that every client heals differently. I understand that this is an elective procedure and is not medically necessary.


    I confirm I will strictly adhere to the typed after-care instructions handed to me, and only use the after-care products given. I understand that complications are possible, particularly if post-procedure aftercare instructions are not followed and if I get an infection post-procedure I will visit my Doctor immediately and accept that it could be due to the fact that I do not live in sterile conditions.

  • I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUSTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL.

  • I have read and understood the above information   

    I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The patch test, which if conducted, may indicate my sensitivity / allergy to the products.

    Client Name   *      
    Signature   *   
    Date   Pick a Date*   

  • Technician Name         
    Signature      
    Date   Pick a Date   

  • Medical Health Form

    Please enter the most accurate and up to date information.
  •  / /

  • Do you agree to NOT consume any of the following 48 hours before your appointment? It is very crucial to your healing process.

    Caffeine, Tea, Energy Drinks, Ibuprofen, Alcohol

    *   

  • Do you confirm you have taken a patch test as advised. Failure to do so would be at your own discretion and your technician cannot be held liable.

    *   

  • Are you presently pregnant or breast feeding?   *   

    Have you received chemotherapy or radiation treatment in the last year?   *      

    Are you currently under the care of a doctor or hospital specialist?   *

    I have had Botox or other injectables   *         

  • Have you had semi-permanent make up before?   
    If YES, how long ago?      
    What procedure? i.e. Microblading, Combination, etc..      

  • I give my consent for semi-permanent make up work to be carried out - which is undertaken at my request and in full understanding of all the points listed

    Client Name         
    Signature      
    Date   Pick a Date   

    Technician Name         
    Signature      
    Date   Pick a Date   

  • For a re-touch procedure only (please tick)    

    Any change in your health?       
    Date of re-touch procedure   Pick a Date   
    Signature      

  • Should be Empty: