Permanent Make Up Medical Form2018-07-10T12:48:06+00:00

Permanent Make Up Medical Form

To be completed by the client

Section 1 - Personal Details


I agree for you to take photos BEFORE, DURING or AFTER my procedure to be kept in my case file. (These photos will not be used for any other purpose unless you give written consent.)

Section 2 - Allergies


Patch testing for allergies

Patch test / waiver. Please tick A or B below.

(A) I understand that a skin test can determine within 24 hours if I will have a reaction to the products, but that it is inconclusive regarding whether I will have an allergic reaction at any time in the future. I choose to waiver my option to an allergy test and wish to proceed with the treatment.

(B) I have undergone / been offered an allergy test prior to my initial treatment and thereby release the technician from any liability related to any allergic reaction to applied pigments or other products used after the procedure, or at a later date.

Titanium Dioxide
Titanium Dioxide is a clear ingredient in our pigments and is not always visible in the skin, even though it may be present. Some cosmetic lasers will permanently alter the colour of Titanium Dioxide, therefore it is vital that you inform your laser specialist where your micropigmentation procedure is. Your laser specialist will then take steps to ensure any adverse reactions.

Nickel
I understand there are traces of nickel in some needles and pigments. This may affect me if I have an allergy to nickel. (In this case a patch test is highly recommended)

Section 3 - Tattooing Act


To comply with the Tattooing Act please tick Yes or No to the following questions.

Section 4 - Current Health


Do any of the following apply? Please tick Yes or No to the following questions. All answers will be treated with the strictest confidence.

Section 5 - Terms of your treatment


Please choose Yes if you agree or No if you disagree. Your specialist will check through and ensure you understand and accept these terms.

IF YOU ANSWERED 'YES' TO ANY QUESTIONS: