MICROPIGMENTATION CONSENT AGREEMENT FORM | Advanced body sculpting and laser center.

MICROPIGMENTATION CONSENT FORM

MICROPIGMENTATION CONSENT AGREEMENT

This form is designed to give information regarding semi-permanent eyebrow, lips and eyeliner micropigmentation application. If you have questions, please don't hesitate to ask. Micropigmentation is the process of depositing pigment into the epidermal layer of the skin and is a form of cosmetic pigmentation. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are stickily adhered to. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.

POSSIBLE RISKS AND COMPLICATIONS

Pain: To minimize discomfort, we will apply topical anesthetic on the working area.
Uneven Pigmentation: This can result from poor healing. Your follow up appointment will likely correct any uneven appearance.
Anesthesia: Topical anesthetics are used to numb the area to be pigmented. Lidocaine, Prilocaine, Benzocaine, Tetra Caine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these, please inform us now.
Allergie Reaction: We use organic pigments for all our pigmentation procedures. This helps minimize possibility of allergic reaction.

Consent and release for procedures performed:

Signed

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Date / Time

STATEMENT OF CONSENT AND RECITALS:

(PLEASE READ AND INITIAL ALL LINES)

Check If Yes

Aftercare instructions have been explained to me and a soft of the aftercare will be given to me, which I will follow to the best of my ability. If I have questions I will call or email you.

I understand that Retin A, Renova, Alpha Hydroxyl and Glycolic Acids must not be used on the treated areas. They will alter the color.

I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.

I accept the responsibility for explain to you my desire for specific colors, shape, and position for any procedure done today.

I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch up session within 60 days.

Pictures or Videos will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed.

I certify that I have read the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered.

Signature

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Date / Time

CLIENT MEDICAL HISTORY FORM

Date / Time

Age

Passport Number

First Name

Last Name

City

Phone/Mobile

Do you presently have or previously had any of the following: (check yes or no)

Diabetes

Yes

Hepatitis (A, B, C, D)

Yes

Alcohol in the last 48hours

Yes

Abnormal Heart Condition

Yes

Pregnant now/ Breast feeding now

Yes

Autoimmune Disorder

Yes

Oily Skin

Yes

Chemotherapy/ Radiation

Yes

Accutane or acne treatment

Yes

Taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin, etc.

Yes

Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine etc.

Yes

Any diseases or disorders not listed:

Yes

Diseases or disorders not listed:

Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?

Yes

I agree that all the above information is true and accurate to the best of my knowledge.

Signature

Sign Here

Date / Time

MICROPIGMENTATION CONSENT AGREEMENT

POSSIBLE RISKS AND COMPLICATIONS

STATEMENT OF CONSENT AND RECITALS:

CLIENT MEDICAL HISTORY FORM

Do you presently have or previously had any of the following: (check yes or no)

Address

Contacts