Previous Lesson

General Consent and Procedure Consent Form – Document 6

General Consent and Procedure Consent Form – Document 6

 

Clients full name…………………………………………………………Mr/Mrs/Miss/Ms

 

Address……………………………………………………………………………………….

 

…………………………………………………………………………………………………..

 

 

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

 

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

 

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

 

I understand that a sensitivity yet for pigment does not guarantee I will not have an allergic response.  I am aware that an 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 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 might leave a light residue of colour.

 

I accept that the highest standards of hygiene are met, and that sterile disposable needs 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, and this is included in the initial price.

 

I understand that the control procedure, if required, will be performed 1-3 months after the initial procedure and that after a 3-month period I will be charged an addition fee for any procedures.  I understand that a control procedure take place 3 -4 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 might migrate under the skin, however this is a rare occurrence.

 

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

 

I understand that loss of any eyelashes during the healing process 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 understand in rare cases that corneal abrasion can occur during the eyeliner procedures.

 

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 dependant 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 – 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 the skin tones, skin type, age and skin conditions.  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 if ii have had a previous outbreak of cold sores/herpes simplex and receive a lip enhancement I may have an outbreak again following the procedure.  I have been made aware that anti-herpes medication is available over the counter or on prescription and has been shown to prevent or minimise such outbreaks.

 

I am aware that if I have had a previous eye disorder or eye infection and receive an eye enhancement the disorder may reoccur.  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 enhancements I may wish to have someone drive me home.

I understand that I may experience dry lips for up to 2 weeks following permanent cosmetic lip enhancement.

 

I understand that scar camouflage procedures require skin colour-matching teste before the procedure commences and will not give the result of an undetectable scar.

 

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 an MRI scan within a 3-month period of receiving the procedure.

 

I agree to follow all the pre-procedure and post -procedure instructions as provided and explained to me by the practitioner.  I understand that infection and possible scarring can occur if I do not adhere to the said instructions.

 

To my knowledge I do not have any physical, mental or medical impairment or disability that might affect my well-being as a direct tor indirect result of my decision to have the procedure done at this point in time.  I am at least 18 years old.  I am not under the influence of drugs or alcohol.

 

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

 

I CERTIFTY THAT I HAVE READ AND HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE PERMANENT COSMETIC ENHANCMENT OF MY OWN FREE WILL

 

I have read and understood the above information

 

Client name……………………………Signature…………………………Date……..

 

Practitioner name…………………….Signature…………………………Date………

 

 

      Please tick this box if you do not wish us to send further information to you.