Consent form – Makes Consense

Date*
DD dot MM dot YYYY
Technician Name:*
Treatment*
Client Name*
Prefix First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number*
Date of Birth*
DD dot MM dot YYYY
Email*
Medical Information
- Alopecia
- Anemia
- Asthma
- Blood thinners
- Breastfeeding
- Cancer
- Diabetes
- Eye disorder
- Haemophilia
- HIV
- Hyperpigmentation
- Lupus
- Pregnancy
- Skin disorder
Tick all that apply to you
Are you receiving any ongoing medical treatment? If yes please give details:
Please list any medication you are currently taking:
Have you had any form of micropigmentation previously? If so please state area and date
Have you had treatment for depression or anxiety related conditions within the last 12 months?
Consent*
I agree this micropigmentation procedure is entirely elective and not medically necessary. This is purely a cosmetic procedure.
Consent*
I have been offered an allergy test prior to my treatment. I understand that allergy tests can be inconclusive, and the pigment can remain in the skin indefinitely.I release the technician from any liability if an allergy occurs for the longevity of the micropigmentation. If I refuse the allergy test I agree to sign a waiver to release the technician from liability.
Consent*
I agree to my photographs being used on social media for promotional purposes.
Consent*
I agree to take a course of anti viral medication from my GP if I suffer from cold sores, a week before and a week after treatment (lips only)
Consent*
I understand that there could possibly still be a risk of an outbreak although unlikely
Consent*
I understand this is a multi stage treatment, normally two sessions, six weeks apart. The procedure is not deemed complete until 6 weeks after the second session, known as the retouch. I agree if I do not return for the retouch within 12 weeks I may have to start again.
Consent*
I fully understand regular exposure to choline may fade the micropigmentation faster than normal.
Consent*
I accept an element of discomfort and there may be redness and soreness after the treatment is complete. This normally subsides within 24 hours.
Consent*
I understand that if I have botox in the area it can lift the brows unevenly.
Consent*
I understand that the sun and sun beds break down the pigments quicker, therefore more regular refreshes will be necessary.
Consent*
I confirm I will follow the aftercare instructions given to me by my technician, I understand that if I don’t follow these correctly the result will be poor. I agree to keep the area clean and if I get an infection post treatment its due to natural elements that are out of the technicians control once you leave the clinical environment.
Consent*
I will agree the drawn on shape with the technician prior to the treatment starting
Consent*
I have witnessed the area being wrapped to prevent cross contamination to the best of the technicians abilities, individually wrapped sterile needles, and disposable consumables.
Consent*
I understand that the area may tingle slightly when having an MRI or CAT scan. This is normal and doesn’t present a problem.
Consent*
I fully understand that although the pigment will fade, in some circumstances it may never completely leave the area. The pigment breaks down and can change colour, regular refreshes keep it looking fresh.
Consent*
Having read all the information I consent to the procedure. I fully understand each point and accept full responsibility if any complications arise. I understand this is a safe procedure if done correctly and complications are rare.
Consent*
Please note that any form of laser can alter the colour of the micropigmentation. I understand that there may be traces of titanium dioxide present in the pigment which will prevent laser treatments in the particular area from this date onwards.
Signature*
Date*
DD dot MM dot YYYY
Patch Test Consent*
I agree that it is my choice to be allergy tested, also known as patch testing, I understand if I have a reaction within 24 hours then I cannot go through with the treatment and do not hold the technician responsible for this reaction. I understand that I could develop an intolerance at any point whilst the pigment remains in the skin, which can be 1 – 5 years or in some cases indefinitely.
Name*
Prefix First Middle Last
Signature*
Date*
DD dot MM dot YYYY
TREATMENT LOG
Treatment
LOT
Expiry
Notes
To be completed after treatment:
I confirm I have accepted the aftercare instructions, I understand failure to follow instructions will lead to a poor result.
Signature*
Date*
DD dot MM dot YYYY
I confirm I am happy with the treatment I have received today and agree the technician has applied the micropigmentation as specified
Signature*
Date
MM slash DD slash YYYY
I agree to keep the area as clean as possible to prevent infection
Signature
Date*
DD dot MM dot YYYY
I understand the treatment is not deemed complete until the retouc, which can be done no sooner than 6 weeks time.
Date
MM slash DD slash YYYY
Before images
Before images
Before images
During images
During images
During images
After images
After images
After images

TREATMENT LOG

To be completed after treatment:

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