CONSULTATION FORM

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY :

The following information will only be used to assess your Permanent makeup goals, determine which treatments are appropriate for your skin condition and to avoid any possible reactions. If you are unsure of any of the following or have any further questions please contact Jordan personally via email on aestheticsjh@gmail.com

Permanent cosmetics are a form of tattooing.
Re touch procedures may be required.
A healing period of four to eight weeks is required before a re touch procedure can be performed.
On rare occasions the pigment may migrate under the skin.
Applications of permanent cosmetics can be painful.
The pigment will fade.
Immediately after the treatment, the pigment can be 30 to 50% darker than desired result.
There may be immediate or delayed allergic reactions. However, allergic reactions are very rare.
A negative allergy test result will not guarantee that you will not have an allergic reaction.
Allergic reactions to anaesthetics can occur.
Permanent cosmetics cannot be applied to pregnant or nursing women.
Permanent cosmetics cannot be applied to a person under the age of eighteen.
Infections can occur if aftercare instructions are not followed correctly.
There may be swelling or redness.
You may experience minor bleeding.

This information is not intended to alarm you; however it is imperative that you are informed of the risks involved.

HAVE YOU RECEIVED CHEMOTHERAPY OR RADIATION IN THE LAST YEAR?

Yes

ALLERGIC TO ANAESTHETICS OR ADRENALINE?

YES

ALLERGIC REACTIONS

Allergic reactions can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction response may display redness, itching, a rash, blistering, dryness, or any other symptoms with allergy.

NUMBNESS

We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is completely numb, while others say they experience some discomfort.

PROCEDURE

For all procedures a cream or gel topical anaesthetic is placed over the treatment area for 15 - 20 minutes, then carefully removed prior to treatment. As a result of the treatment, combined with the use of anaesthetic you can expect to experience swelling and redness that could last between 1 and 4 days. You should always follow your post procedure aftercare instructions.

GENERAL CONSENT AND PROCEDURE PERMIT

If any unforeseen conditions arise in the course of this procedure(s), calling in his/her judgment in addition to, or different from those now contemplated, I further request and authorise him/her to do whatever he/she seems advisable and necessary in the circumstances.
I accept responsibility for determining in the colour, shape, and position of the permanent cosmetic procedure as agreed during the course of my consultation.
I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment.
I fully understand and accept that non – toxic pigments are used during the procedure and that cosmetics enhancements achieved may fade over a period of 1 – 3 years. Even though the colour has faded the colour will stay in the skin indefinitely.
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 understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable result, and that 100% success cannot be guaranteed during the first procedure. I understand that this is why I will need to return for a retouch procedure.
I understand that a retouch procedure will be performed 4 – 8 weeks after the initial procedure and that after this period I will be charged an additional fee for any further work. I understand that it is my responsibility to book the appointment at a time convenient for me.
The result of the procedure is determined by the following: medication, skin characteristics – (dry, oily, sun-damaged skin and thickness of the skin.) natural skin undertones – (blending with chosen pigments.) personal pH balance of the skin, which changed from visit to visit. Alcohol and smoking, and post procedure care.
Upon completion of the procedure there may be swelling and redness of the skin, which will subside between 1-4 days. In some cases, bruising may occur. You may resume normal activities immediately following the procedure; however, using cosmetics, excessive perspiration and exposure of the sun to the affected area should be limited. See specific post-procedure instructions for details. You can, however, be assured the procedure even after only 1 treatment, looks acceptable so that you should be able to feel comfortable appearing in public without additional makeup on the affected area.
I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary in colour according to skin tones, skin type, age and skin conditions. I understand that some skin accepts pigment more readily than others, and no guarantee to an exact effect or colour can be given.
I am aware that the lip procedure may stimulate any dormant virus such as herpes (cold sores.)
To my knowledge I do not have any physical, mental or medial 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 over the age of 18 years. I am not pregnant. I am not under the influence of drugs or alcohol.
I agree to follow all pre – procedure and post – procedure instructions as provide and explained to me by the technician. I confirm that I have received copies of all the relevant aftercare instructions.
Being of sound mind and body, I hereby release all responsibility. I accept any and all responsibility myself for any consequences that might stem from my decision to have any permanent cosmetic procedures performed by the technician.
For the purpose of the documentation, I also consent to the taking of before and after photographs of said procedures for the record purposes and for use in presentation portfolios.

I CERTIFY THAT I HAVE READ AND HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WHERE MADE AND I ACCEPT FULL RESPONSIBILITY FOR THESE AND OR OTHER COMPLICATIONS WHICH MAY ARRISE OR RESULT DURING OR FOLLOWING THE COSMETIC TATOO PROCEDURE(S) WHICH IS TO BE PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT AND PROCEDURE PERMIT.

I confirm that the above information is correct.

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