Basic Information:

Your full name
Your Date of Birth

Address
Post Code

Email Address
Contact Number

By checking the boxes below, I state that I have read and understood the terms and conditions:

I absolutely understand micropigmentation is an art process and not an exact science and that every client heals differently. I understand that this is an elective procedure that is not medically necessary and is a multi treatment process.

I absolutely understand that I am entering into a multi treatment contract until my procedure is deemed complete and that I agree to the cost of £245 for the initial treatment and £140 for top up treatments.

I have undergone or been offered an allergy test prior to my treatment and hereby release the technician from any liability related to any allergic reaction or secondary reaction to applied pigments or other products used during or after the procedure or at a later date. Pigments are mainly composed of iron oxide, alcohol, glycerol and water.

All needles and machine parts used are individually wrapped, sterile and disposed of after each treatment. I accept that whilst in treatment room all universal precautions are taken but my risk of infection begins the moment I leave the centre.

I confirm I will agree all colours and shape prior to any work commencing, and that the technician will keep a log of colours etc, chosen to assist further visits. I agree to before, drawn and after photographs being taken. These photographs will be stored on my file and not used for any other purpose unless I agree in writing.

I accept that after the treatment the direct area treated may show signs of swelling, redness and in rare cases bruising. I accept some discomfort.

I accept that colour chosen and applied may appear darker for up to 7 days after treatment then will start to lighten after, I accept that I need to return for additional applications and that if I don’t return the makeup will fade faster in the skin and additional work will be charged for.

I confirm I will strictly adhere to the aftercare instructions given to me and only apply aftercare products given to the treated area. I also accept that complications and rejection of pigment are possible if aftercare instructions are not followed and that should I get an infection post treatment that I will immediately visit my GP and accept that this is possibly due to the fact that I do not live in sterile conditions. If I have any concerns I will telephone my technician to discuss.

I fully understand that colours will stay visible in the skin for 1 to 5 years and in some cases indefinitely. Also that light based colours fade faster than dark based colours and that colours change with time and the technician cannot guarantee the longevity of colour in the skin after each application this varies from person to person. I confirm and accept that should I use sun beds or frequent sun exposure, glycolic acids, aha products that this will fade my colours faster.

I understand that laser treatments or further surgery may alter my micro pigmentation and I do not hold the technician responsible.

I understand that if I have an MRI or CAT scan micro pigmentation may tingle in the treated area this will not affect the treatment.

I understand that if I wish to change either the colour, thickness or shape after my first application of cosmetic tattooing that additional cost will be incurred as the area will need an additional treatment.

I confirm that I have not consumed alcohol within the last 24hrs. (24 hours before the treatment)

MEDICAL INFORMATION AND MEDICATION

1. Are you currently under the care of a doctor or hospital specialist?
—Please choose an option—YesNo
If Yes please give details

2. Please list any medication you are taking including painkillers and or antibiotics
—Please choose an option—Yesno
If Yes please give details

3. Have you had micropigmentation before? If Yes please give details:
—Please choose an option—Yesno
If Yes please give details

4. Please Check all conditions that apply to you:
Allergies to DyeAlopeciaAnaemiaAsthmaBreastfeedingCancerCataracts surgeryDiabetesDry eyeEpilepsyEye disorderHaemophiliaHeart conditionHepatitisHIVHyper pigmentationKeloid scarringLupusPregnantSkin disorderTBThyroid conditionNone

5. Please specify any heart conditions/skin conditions or allergies

PATCH TEST CONSENT

I have decided to have an allergy test. I understand that I may have an allergic reaction to the micropigmentation products within 24 hours and that if I do I will not be able to have a micropigmentation procedure.

I do understand that if no allergic reaction is evident within 24 hours that it is not construed that I may not have a reaction at a later date (secondary reaction). I affirm that I will release the technician from any liability to an allergic reaction should I wish to proceed with a micropigmentation procedure.

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DATE OF PATCH TEST:

PATCH TEST WAIVER

I understand that a skin test can determine if I will have a reaction within 24 hours to the products tested but that it is inconclusive regarding whether I will have an allergic reaction at any time in the future. Therefore, I waive my option to an allergy test and wish to proceed with a micropigmentation procedure.

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Today's Date:

TITANIUM DIOXIDE DISCLOSURE

Titanium dioxide is present as an ingredient in many pigment colours in small traces but present in larger quantities in lighter formulations and white pigment.

Regardless of what is stated by the manufacturer on the label of the bottle no one can guarantee that white (an essential component used in many colours) is not going to be mixed in pigment. Therefore, by my signature on this form, I acknowledge that I understand that my decision to proceed with a micropigmentation procedure will prevent me having any future laser treatments in the area of my micropigmentation.

I agree that I am happy with the treatment I have received today and the technician has applied the makeup as I have
I agree that I have been given written aftercare instructions.
I confirm I have read and accepted aftercare conditions and will strictly adhere to them.
I agree that if I request that the technician to change the shape, colour or thickness of the first application that another treatment will be needed and that I shall have to pay for this.

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Today's Date: