Regular customers Form

Informed Consent & Clinical Sheet

para Micropigmentación Facial.
Information about Facial Micropigmentation

Facial Micropigmentation is a service whose purpose is to create a long-lasting makeup, in the first basal layer of the skin simulating hair, shadow, eyeliner or a very subtle lipstick. With PAINLESS AND INNOVATIVE TECHNIQUE THAT PERFECTS YOUR FACE. You work on your skin obtaining a HYPERREALISTIC and VERY natural result. It is recommended to perform the touch-up between 28 and 60 days as MAXIMUM, since after this no warranty is included. The touch-up is included in the cost of your first service. This service allows you to improve the appearance of your face while maintaining naturalness.

Risks of any facial treatment
Here you can find the risks that any cosmetic procedure may have.

THEY ARE RARE, but it doesn't hurt to mention them

You are informed that in case of complications you must inform the specialist and; if necessary; go to your doctor.

You understand that by undergoing these treatments you may run the risk of complications, such as:

Local infection (in case of not following care instructions)

General infection (in case of not following care instructions)

Allergy

Contact dermatitis

Skin reaction

Poor scarring (in the case of very severe keloid skin)

In people with oily and/or sensitive skin, the pigment has less duration.
I hope all the above information has been understood. Otherwise, reread it or write to me on WhatsApp 642

Full Name
Identification
Escriba su numero de cédula
Phone Number
WhatsApp
Email
example@example.com
Emergency Contact

NombreApellido
Emergency Phone Number
Escriba el número de la persona que es su contacto en caso de alguna emergencia

What would you like to do? You can choose more than one option

Eyebrow Micropigmentation
Choose the technique you would prefer or were recommended
Would you like to see another service?

Lip Micropigmentation
Choose the technique you would prefer or were recommended
Would you like to see another service?

Eye Liner
Choose the technique you would prefer or were recommended
Would you like to see another service?

Since the last form you filled out. Is there any new condition/disease you are currently suffering from?

Clinical Sheet

This information is completely confidential and will be handled in the same way. Fer Alvarado assumes no responsibility for false information provided in this form.

In this section you will find the most common ailments and situations, please mark if any of the statements resonate with your situation, in case your ailment is not on the list, you can add it in the statement below. Remember that lying and putting your health at risk is punishable by law.

Rows	Yes	No
Ingest birth control pills or a new contraceptive method
Currently pregnant
Less than 3 months of breastfeeding
Hemophilia
Hepatitis(A,B,C,D,E,F)
Diabetes
Eczema
Epilepsia
Autoimmune Diseases
HIV +
Problems with wound healing
Keloids
Thrombosis / blood clots
Anticoagulants
Heart problems
Pacemaker
Allergies
Botox or Fillers recently or soon
Impetigo
Do you consume caffeine regularly?
Do you smoke regularly?
Antibiotics (in the last month)
Drugs / sensory stimulants
Roacutan or acne treatment
Facial Warts
Angiomas
Urticaria, rosacea, psoriasis or some skin condition
Facial prosthesis
Conjunctivitis
Diabetes not controlled
Recent burns (include sunburn )
Local infection by bacteria, fungi or viruses, herpes
Hypertension
Recent surgeries (less than 1 month old)
Previous tattoo or micropigmentation
None of the above

Please mention if you have any situation not listed above.
If your response to any condition was YES, please indicate the name of the medicine and the regularity with which you consume it
Medical note required for patients with Diabetes, completed oncological treatments, cardiopathies, ongoing psychiatric treatment or pregnant women.

Buscar archivos

Cancelof

Guarantees
1. DOES NOT APPLY when I have one or more previous jobs

2. DOES NOT APPLY when more than 60 calendar days have passed since I had the first session

3. DOES NOT APPLY when I come for a retouch without having had the first session with Fer

4. DOES NOT APPLY when I had the maintenance retouch two years after the last session and the pigment is not visible

5. DOES NOT APPLY if I have gone to get retouches elsewhere even though Fer did the first session

6. DOES NOT APPLY when in the retouch I decided to make my eyebrows, lips or liner thicker than the initial design

7. DOES NOT APPLY when I come to my annual retouch and the color is too faint (people with oily and/or sensitive skin)

8. APPLIES when I have completed all the sessions recommended by Fer

9. APPLIES when I have done my retouches during the appropriate dates

10. DOES NOT APPLY if the pigment was removed by the client. (You can notice it if there is a pronounced gap, without any background color)

11. ONLY APPLIES once.
Select "UNDERSTOOD" at the end of the previous reading

Attendance Rules

1. The respective deposit for your appointment must have been paid

2. You must arrive at least 5 minutes before your appointment time.

3. If you arrive 15 minutes late, your appointment will be considered completed and you must reschedule and pay the deposit again.

4. DO NOT arrive with companions, if necessary you may come with a MAXIMUM of 1 companion.

5. It is recommended NOT to come with children, appointments have a MINIMUM duration of 2 hours.

6. You must follow the cleaning instructions provided in your confirmation appointment to enter the studio.
Select "UNDERSTOOD" to continue

Equipment used

1. It will be opened in front of you.

2. The needles to be used are completely new, sealed, and have an expiration date.

3. The pigment applicator and the anesthesia applicator, which are completely new, will be presented to me.

4. The inducer to be used in the treatment is properly processed and disinfected.

5. The pigment used on your skin is FDA approved and Ministry of Health approved; it is PhiBrows SUPE and/or SUPER brand; by Branko Babic and Perma Blend Pigments of the Perma Blend brand

6. The bed will be disinfected and the sheets to be used will be changed before your arrival

7. All the equipment to be used will be prepared in advance

8. The entire process that we will carry out both in the appointment and afterwards will be explained to you. You can ask all the questions you want.
Select "UNDERSTOOD" after finishing reading the above points.

Reservation Deposit

Por favor tomar una captura de pantalla al realizar el depósito
- Canceled appointments will lose their deposit if they do not communicate 48 hours in advance to notify and reschedule. You will only have the opportunity to reschedule a second date ONCE
- Not attending loses the deposit and must pay the new appointment in full in advance.
- You must attach the deposit receipt, please take a screenshot for later
- The reservation deposit is $45 transfer.
- In SINPE PAYMENT DETAIL: please write the date of your appointment.
  You can make your sinpe to this number 6028-4778, in the name of María Fernanda Alvarado Cespedes
- BAC San Jose
María Fernanda Alvarado Céspedes

BAC: 941370843

IBAN: CR15010200009413708438
Please attach the screenshot of the reservation deposit. Either from sinpe or online payment.

Buscar archivos

Cancelof
Choose your slot if you have not scheduled it via WhatsApp. If you did it via WhatsApp, the schedule you are looking for MAY NOT APPEAR because it is already blocked for you. If it is done directly through this medium when entering your information, please add the prefix of your phone number, so that a message with important information automatically arrives. Example +506 60284478

Rows	I understand
1. You are informed that micropigmentation is the insertion of pigment into the skin. This pigment will disappear over time through the lymphatic system. The duration of the product on your skin will depend on its health and its metabolism. Each person is different and one result should not be compared with another.
2. You are informed that micropigmentation can alter your physical appearance, facial expression; as well as the possible modification of your natural eyebrow, in some cases it is necessary to do a partial hair removal to obtain an adequate result (no area will be waxed in its entirety or without your consent)
3. It is clear that when you change your mind or regret proceeding with the treatment while present in the study, you must cancel 50% of the cost of it, since the space has been reserved exclusively from the moment of the reservation deposit.
4. You are informed that during the procedure you may feel some discomfort, due to your sensitivity and pain threshold. (I do not recommend attending your appointment in the days before or in the middle of the menstrual period)
5. The design presented by Fernanda is the one that best adapts to her bone and muscular facial structure. It will be sought to maintain the natural appearance, however some cases require the modification of the partial or complete position of certain points of eyebrows, lips or eyelid
6. You are informed that, not in case of attending your appointment without prior notice or the total cancellation at the last minute of your treatment without weighty reason; it implies the complete loss of the reservation deposit, and will go to the blacklist. (You will not be attended to anymore)
7. The technician has full authority to postpone / cancel the appointment in case your skin / health is not optimal for the treatment on the scheduled day
8. You are reminded that two different local anesthesias will be used, one on closed skin and one on open skin. Both contain Lidocaine, Tetracaine, Epinephrine, Prilocaine and Adrenaline. Please inform if you have any allergies or rejection of these components. You can take an allergy test if you don't know if you have any allergies, the cost of the test is 10,000 extra.
9. If you decide not to take the allergy test, you assume all the risk of a possible allergic reaction and release the technician from all responsibility. Allergies are UNCOMMON, but it is reported to be a risk in any aesthetic procedure.
10. You are informed that at the beginning and end of the treatment, photographs and videos will be taken for advertising purposes. Some of those images will be sent to you on your WhatsApp
11. You are reminded that there is individual variability in the response of any aesthetic treatment. That despite the proper choice of technique and correct application of the treatment, there may be effects (very uncommon), such as stinging, inflammation, redness, peeling or blisters, the days after treatment
12. It is recommended to follow the recommendations given to you at the end of your appointment to the letter. They will be sent to your WhatsApp and explained in detail on the day of your appointment. In case of not following the care, I am given full responsibility for any problem derived from poor care, exempting the specialist from subsequent inconveniences.
13. You are reminded that you will be given a cream for aftercare in the first session, which carries a reusable container that you must bring with you on the day of annual maintenance. (this is included in the total value) you must give it for 20 days after treatment and yields much more. In case of loss of this, the value of a new one is ₡3,000 that must be paid only in cash or transfer.
12. After the treatment there will be a loss of crusts, likewise the intensity of the treatment will be reduced by 30% to 40% and the thickness by 10% to 20%, in the first week. Clarifying that in OILY, MIXED and/or SENSITIVE skin, or with hormonal problems, they will lose 50% or more of color. These skins may require EXTRA TOUCH-UPS or before the specified time
13. If you are not a candidate for any of the procedures, your reservation deposit will be refunded after 48 hours after the delivery of the form. Please add a SINPE number or account number; in the statement "others..."; in case you are not a candidate

Informed Consent & Clinical Sheet

Information about Facial Micropigmentation

Risks of any facial treatment

Eyebrow Micropigmentation

Lip Micropigmentation

Eye Liner

Clinical Sheet

Guarantees

Reservation Deposit

Service Contract