Candidates who are contraindicated (who we are unable to treat): Under 18, Pregnant or breastfeeding, HIV, Undergoing Chemotherapy: *
Contraindications that seek GP consent: Roaccutane, Auto-immune conditions, Insulin dependent diabetes, Epilepsy, Haemophilia, Hepatitis B and C, Keloid Scarring, Blood thinning medication, Heart Disorders: *
I confirm I have completed a Patch Test for this procedure within 6 months of the treatment date and aware a negative allergy test result will not guarantee that I will not have an allergic reaction to pigment and anaesthetic: *
I confirm I have chosen to waiver the patch test and release the therapist from liability: *
CONSENT TO HAVING MICROPIGMENTATION
I understand the importance of withholding any medical conditions may be detrimental to my health and the outcome of the procedure.
I confirm that it is my responsibility to ask sufficient information about the treatment.
I am aware that the treatment is carried out by use of needle/blade and pigments, to enhance facial features.
I understand the procedure is a process requiring multiple applications to achieve desirable results and that 100% success cannot be guaranteed.
I understand this is why I need to return for a retouch procedure.
I understand that a retouch procedure will be performed 6 weeks after the initial procedure and after a 3-month period I will be charged an additional fee for any further work: *
RESULTS
The result of the procedure is determined by Medication, Skin Characteristics (old/young, dry, oily, sun-damaged and thickness, pigment retention low oily damaged skin) Natural skin undertones and lifestyle Sun Exposure, Skin Exfoliating.
I understand that some skin types except pigment more readily than others and no guarantee to an exact effect or colour can be given. Immediately after the procedure, pigment can be 30/50% darker than the desired result.
On rare occasions the pigment may migrate under the skin and the true colour will be seen one month after each procedure: *
POSSIBLE SIDE EFFECTS & COMPLICATIONS
Allergic reaction. Swelling and redness following the procedure. You may experience minor bleeding. Infections can occur if aftercare is not followed. Lip procedures may stimulate dormant virus such as herpes (cold sores).
Eye procedures may stimulate dormant eye disorders or eye infections and that some medication can prevent absorption of the pigment.
If you have a MRI scan within 3 months of your procedure we recommend that you discuss this with your doctor.
Please inform the National Blood Service if you donate blood as you may not be eligible to give blood for a year post application. Avoid using cosmetics, excessive perspiration, wetting and sun exposure for 2 weeks: *
ACKNOWLEDGMENT
I accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure.
I have been informed that the highest standards of hygiene are met and that sterile disposable needles and pigment containers are used for each individual client, procedure and visit.
I agree to follow all pre-procedure and post-procedure instructions. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the procedure(s).
I understand and acknowledge that payments for the above procedure are non-refundable and due at the time of service.
I further agree in the event of non-payment, to bear the cost of collection and/or Court cost and reasonable legal fees should this be required.
I hereby authorise Dolly Patel to administer such treatment to me and agree to hold her free from any claims, suits or damages for any injury or complications resulting from this treatment.
I confirm that I accept all liability: *
