Fer Alvarado Studio

Informed Consent & Medical Sheet

For Facial Micropigmentation.
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 (if care instructions are not followed)

General infection (if care instructions are not followed)

Allergy

Contact dermatitis

Skin reaction

Poor healing (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, please reread or contact me via WhatsApp 🙂

Enter your full name

Primer Nombre Apellidos
Identification
Escriba su numero de cédula
Address

Provincia | Ciudad

País Teléfono de Comtacto de Emergencia

Nombre de Contacto de EmergenciaCountry
Phone number
WhatsApp
Email
example@example.com
Date of birth

DíaMesAño
Gender
Emergency contact

NombreApellido
Emergency phone number
Escriba el número de la persona que es su contacto en caso de alguna emergencia
How did you hear about my service:

Other

Referrals

When referring someone, you can receive a 5% discount on your next service. This percentage is cumulative up to 30%; of course, it applies if your referral is carried out its procedure. And expires every December 31 of the current year.
Referrer's information

NombreApellido
Phone

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

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

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

In this section you will find the most common ailments and situations, please mark if any of the statements resonate with your situation, if 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
Epilepsy
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 (including 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.

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Guarantees
I invite you to review the guarantee of the micropigmentation services

https://www.canva.com/design/DAHD-ah-5HI/WQmiHCebiAbRVXM8h7ol1Q/view?utm_content=DAHD-ah-5HI&utm_campaign=designshare&utm_medium=link2&utm_source=uniquelinks&utlId=h1ec2705482
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 show up with companions, if necessary you may show up with MAXIMUM 1 companion.

5. It is recommended NOT to show up 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, come 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 used in the treatment is properly processed, disinfected.

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

6. The stretcher 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 beforehand

8. The entire process that we will carry out both in the appointment and afterwards will be explained to you. You can ask any questions you want.
Select "UNDERSTOOD" at the end of the previous points.

Reservation Deposit

Por favor tomar una captura de pantalla al realizar el depósito
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 you do it directly through this means when entering your information, please add the prefix of your phone number, so that you automatically receive a message with important information. Example +506 60284478
- Canceled appointments will lose their deposit if they do not communicate 48 hours in advance to notify and reschedule. Only one second date reschedule opportunity will be given
- 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. Or through this link to Pat with credit card https://tp.cr/l/MTk1NTI4
- BAC San Jose
María Fernanda Alvarado Céspedes

BAC: 941370843

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

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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.
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

Photographs Please, to verify the work you have, it is essential for me to review in advance the correction that needs to be made. This photograph is very important for the process. 1. Completely clean face. No creams, no sunscreen, NO MAKEUP. 2. With completely natural light. Preferably in front of a window in the morning hours. |Photos sent with phone flash, in the dark, with lamp or bulb light will be rejected| 3. Frontal. That you can see from your forehead to your chin. | this is to verify measurements and offer two design options.| Photos that do not meet these requirements will be rejected.
Photographs

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By submitting this questionnaire and accepting the above statements, you release María Fernanda Alvarado Céspedes; ID 1-1455-0541; technician in micropigmentation of Fer Alvarado Studio; cc. My Brows CR, legal ID 3-101-803654; located in San José, San Sebastián, Urbanización Las Margaritas, house #126; from any side effects that may occur after the micropigmentation procedure in case of having omitted any information about illness/condition that you may have as a client and did not mention, or did not read correctly.
Should be Empty:

Informed Consent & Medical Sheet

Information about Facial Micropigmentation

Risks of any facial treatment

Referrals

Customer Expectations

Eyebrow Micropigmentation

Lip Micropigmentation

Eye Liner

Guarantees

Reservation Deposit

Service Contract