Semi-Permanent Brow Specialist in Newark-on-Trent

Treatment Form

Pola Beauty Permanent make up Pre-Treatment Form

Consent form

Date of Treatment

Full Name *

Address *

Postal code

Phone *

Date of birth *

Treatment Today

Please note that if considering laser hair removal to inform the laser specialist that you have micro pigmentation as laser can drastically change the colour of the treated area if in direct contact.

I hereby consent to the application of micro pigmentation. I have read and fully understand all the points listed in this procedure consent form. I accept full responsibility for any complications that may arise during or following the treatment as a direct result of failing to disclose relevant information regarding my health or current medications. I hereby give my written consent for a micro pigmentation procedure to be applied as requested by me on this consent and procedure agreement.

Please sign to confirm you have understood and complied with the instructions above. *

Clear

Date *

MEDICAL INFORMATION AND MEDICATION

TO BE FILLED IN BY CLIENT:

Are you currently under the care of a doctor or hospital specialist?

Yes

No

If yes, please give details

Please list any medication you are taking including painkillers and or antibiotics.

It has been explained to me by my technician that the medications listed above can have an impact on my treatment. Although the exact affect cannot be known, it has been explained that bleeding, bruising and longer healing times as well as possible poor retention of colour are all possible results from taking the above medications and I am happy to proceed.

Please sign to confirm you have understood and complied with the instructions above. *

Clear

Have you had micro pigmentation before? If yes please give details:

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.

Patch Test Consent Signature *

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*PRE CARE - PLEASE READ FULLY*

Your Pre Care is an important step in achieving the desired healed results. As we are working with living tissue, ensuring the skin is in optimum condition is vital to our results. Please ensure you fully read the below and agree to follow these steps.

3. Position each plaster on to one of the following areas:

1.Please ensure any tinting / waxing or threading is carried out at least one week prior to your appointment.

2. Please ensure you drink plenty of water in the weeks leading up to your appointment, hydration is key for skin healing.

3. 1-2 weeks before your treatment, gently exfoliating any dead skin cells and moisturise the area twice a day.

4. Please avoid any retinol around the brow area for a minimum of 8-12 weeks.

5. Ensure you use a broad spectrum SPF daily.

6. Avoid drinking large amounts of coffee, taking ibuprofen, aspirin (unless medically advised) and alcohol the night before your treatment.

Cancellation Policy

1. A non refundable, non transferable booking fee is required to secure all new appointments.

2. If you cancel your appointment with less than 24 hours of your appointment, this will result in a fee for the total amount of your appointment.

4. You must agree to follow all pre and post aftercare given. Failure to do so will effect your finished results. If aftercare is not followed and an additional treatment is required

5. Please ensure you are happy with the treatment before leaving the premises.

I agree that I am happy with the treatment I have received today, the technician has applied the makeup as I have requested. *

Clear

I agree that I have been given written aftercare instructions. *

Clear

I confirm I have read and accepted aftercare conditions and will strictly adhere to them. *

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