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PMU Brow and Body Artist

Consent form for Permanent Cosmetic/Medical Semi Permanent Cosmetic Procedure

Name Jen Fear Brow & Body Artist

Tel No: 07770931484

Name of Practitioner: Jen Fear

Client DOB
Day
Month
Year
Age ID of Client Seen:
Yes
No

Site of Procedure: EYEBROWS

I hereby authorise JEN FEAR to perform upon myself a permanent cosmetic/medical enhancement. If any unforeseen condition arises in the course of the procedure(s) I further request and authorise her to use her full judgement and do whatever she deems advisable and necessary in the circumstances.

I understand that permanent cosmetic/medical enhancement is an advanced form of tattooing.

I accept responsibility for determining the colour, shape and position of the enhancement as agreed during the course of my consultation.

I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs.

I am aware that a sensitivity reaction to anaesthetics can occur and accept all responsibility if allergic response occurs.

I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over the course of 1-3 years. Even though the colour has faded, the pigment will stay in the skin indefinitely and may leave a light residue of colour.

I accept that the highest standards of hygiene are met, and that sterile disposable needles are used for each individual client, procedure and visit.

I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I need to return for a control procedure that is included in the initial price.

I understand that the control procedure, if required, will be performed 1-2 months after the initial procedure and that after this period I will be charged an additional fee for any procedures. I understand that a control procedure takes place 4-8 weeks after the initial application to allow the procedure site to fully heal. I will book the appointment when it is convenient for both parties.

I understand that the pigment may migrate under the skin; however this is a rare occurrence.

I understand that permanent cosmetic enhancement is an invasive procedure and the infusion process can be uncomfortable.

I understand that loss of any eyelashes during the healing of permanent cosmetic eye enhancements will result in new eyelash growth over a 4 month period and that eyelash loss is rare and minimal.

I am aware that the result of the procedure is determined by the following:

Medication. Skin Characteristics - i.e. dry/oily/sun-damaged, natural skin undertones, alcohol intake and smoking. General stress, a compromised immune system, poor diet, post procedure care treatment.

I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-4 days dependent on lifestyle. In some cases bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited for up to two weeks following the infusion process.

I understand that immediately after the procedure the enhancement can be 30 to 50% darker than the desired result and can take between 4-10 days to lighten. I understand that the true colour will be visible 1 month after each application, and that the colour may vary according to skin tone, skin type, age and skin condition. I appreciate that some skins accept

colour more readily than others and no guarantee of an exact effect or colour can be given.

I am aware that that if I have had a previous eye disorder or eye infection and receive an eyelash enhancement (semi permanent eyeliner procedure), the disorder may reoccur again. I agree to use the correct medication to prevent such a disorder reoccurring.

I am aware that even though my vision is not affected by permanent cosmetic eyelash enhancements (eyeliner) I may wish to have someone drive me home.

I understand that there are few effective methods for pigment removal. Laser removal has proven successful, however is a process. I agree to inform my doctor of my permanent cosmetic enhancement if I require a MRI scan within a 3-month period of receiving the procedure.

To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well-being as

a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol.

I understand that if I do not allow the technician to complete the procedure, I accept all responsibilities for the result.

For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s).

I absolutely understand that micropigmentation is an art process, and is not an exact science and that every client heals differently. I understand that this is an elective procedure and is not medically necessary. I understand that I will need to return for a second treatment before my procedure can be deemed complete. If heavy make-up is required then I accept that I may require additional work, which I understand is chargeable. I understand that the second treatment needs to be

taken – after one month and before three months. If I do not return in the agreed time scale it is deemed that I am happy with a single procedure and that I will pay for any further procedures taken thereafter. I understand that no money will be refunded to me should I decline the second treatment.

I confirm I will strictly adhere to the typed after-care instructions posted/handed to me, and only use the after-care products given. I understand that complications are possible, particularly if post-procedure aftercare instructions are not followed and if I get an infection post-procedure I will visit my Doctor immediately and accept that it could be due to the fact that I do not live in sterile conditions. If I have any questions or queries after the procedure I will telephone the

technician to discuss.

I fully understand that the skin type of every client is different and have been advised that pigment should stay visible in the skin from 1 to 2 years (and in some cases indefinitely). Also that lighter colours will fade quicker than darker colours, and that colours might change with time.

If considering BOTOX or COLLAGEN please note injectable can alter the position of the eyebrows and lip liner.

If considering facial LASER HAIR REMOVAL please ensure you inform the LHR technician that you have had a semipermanent/micropigmentation lip liner (as laser, if done over the vermilion border, can cause the lip line to change colour.

I understand that future laser treatment or other skin altering procedures, such as plastic surgery, chemical peels, implants, and/or injectable may alter my semi-permanent make-up.

I understand that semi permanent make up fades over time and annual retouches may be required in order to refresh the colour. Semi permanent make up fading depends on medication, skin characteristics (dry/oily/sun-damaged), natural skin undertones, compromised immune system, poor diet, sun/sun beds exposure (use spf 50 cream to protect quick fading),

chemical peels, hormone changes.

RETOUCH APPOINTMENTS

Your procedure may need a retouch to ensure perfect pigmentation. A complementary Top Up is included in the cost of your procedure and must be undertaken between 4-8 weeks after the initial treatment.

It is your responsibility to book this appointment. Failure to attend a scheduled retouch appointment or give 72 hours notice of cancellation of a retouch appointment will waive your rights to the procedure.

The normal cost of a retouch appointment is half of the original treatment price.

I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE

CONSENT FORM AND THAT I HAVE REQUSTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY

OWN FREE WILL.

I have had a patch test and reported no reaction to the PIGMENT
Yes
No
Appropriate Aftercare Information has been given:
Yes
No

I have read and understood the above information (Date of the Procedure)

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