Client NameMr. Howard South Yorkshire Green

Date

05.10.2019

Technician Name:

0.7

Treatment

27 Lodge Lane

Prefix

Mr.

Client Name

Mr. Howard South Yorkshire Green

Middle

South Yorkshire

First

Howard

Last

Green

Address Line 2

Aston

City

Sheffield

ZIP / Postal Code

S26 2BL

State / Province

dascfdsf

Date of Birth

03.10.2019

Address

Aston
Aston
Sheffield, dascfdsf S26 2BL
Map It

Street Address

Aston

Phone Number

(011) 444-2877

Email

Email hidden; Javascript is required.

Consent

I agree this micropigmentation procedure is entirely elective and not medically necessary. This is purely a cosmetic procedure.

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 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 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 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 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 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 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 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 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 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 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 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 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 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

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

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.

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.

Date

16.10.2019

Signature

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.

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

Rev. Lewis South Yorkshire Rowlands

Prefix

Rev.

First

Lewis

Last

Rowlands

Middle

South Yorkshire

Signature

Date

10.10.2019

TREATMENT LOG

TREATMENT LOG

TO BE COMPLETED AFTER TREATMENT:

To be completed after treatment:

Signature

Date

17.10.2019

Date

23.10.2019

Signature

Entry Date

October 27, 2019

During images

FORM-MASTER.jpg

Before images