It is vital that you clearly mark areas which you need further clarification or discussion on to ensure that you are fully informed before your treatment commences

We are unable to perform any procedure on anyone under 18 years of age, pregnant or under the influence of alcohol or drugs

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Full Name
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Date of Birth:
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Age:
Present Age
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E-mail Address
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Address
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Contact Number
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Appointment Type (please tick relevant box)
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Please Tick the Relevant Box

I am Over 18
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I am Pregnant or Breastfeeding
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I am Taking any Blood Thinning Medications
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I Suffer from Coldsore Outbreaks
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Medical Information

1. Are you currently under the care of a Doctor or Hospital Specialist?
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If yes, please list the relevant details of your Doctor and condition here:
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2. Please list any Medications you are currently taking
Medications
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3. Do you feel well and able to have the procedure today?
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4. Have you recently undergone, or plan to have, any elective or necessary surgery?
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If you answered yes to the above question, please state details here
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5.Please tick all Medications/ Medical Conditions that apply to you:
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6. Do you have any allergies?
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If you answered yes to the above question, please state details here
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7. Do you have or are planning to have any Dermal Fillers
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8. Do you suffer from or have any problems with scars healing or bleeding?
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9. Have you currently or previously within the last 12 months had any of the following conditions:
(Please tick any that apply to you)
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10. If there are any illnesses or disabilities that are not listed above but you feel may affect the treatment, please list below:
Illnesses or disabilities
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I understand the importance of my accuracy and complete Medical History. And that withholding any Medical Information may be detrimental to my health and safety during the procedure. I understand that if there is any change in my Medical History that it is my responsibility to advise my Specialist.

Signature:
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Date:
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Photographic Release Form

I fully agree to photographs being taken prior to, during and after procedure

I

Your Full Name
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the undersigned, consent that my technician may use any photographs or video footage taken for promotional purposes.

Signature:
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Date:
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IF YOU HAVE HAD A PATCH TEST AND RESULTS WERE FINE, PLEASE SIGN AND DATE BELOW:

I understand that if no allergic reaction is evident within 24 hours that it is not to be construed that I may not have a reaction at some time in the future. I affirm that I will release the technician from any liability to an allergic reaction should I wish to proceed with a lip micro-pigmentation procedure.

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Consent & Agreement to Treatment

I understand that lip pigmentation is an art process and is not an exact science and that every client heals differently. I understand that this is an elective procedure and is not medically necessary.

I understand that I will need to return for a second treatment before my procedure can be deemed complete. If a heavy make-up look is required then I accept that I may require additional work, which I understand is chargeable. I understand that the second treatment needs to be taken after 4- 6 weeks and before 3 months. I understand that no money will be refunded to me should I decline the second treatment. If you require a third treatment then this will be charged at £150.00

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 or other reaction to applied pigments or other products used after the procedure or at a later date. All needles used are individually wrapped, sterile and are disposed of after each client. I accept that whilst in the treatment room universal precautions are taken but that my risk of infection begins the moment I leave the clinic.

I confirm that I will agree pigment colours and final shape prior to any work commencing and that the technician will keep a log of the colours chosen by myself for my required procedure. All this information will be logged on file to assist with further visits. I accept that after each treatment the area treated may swell . I accept there may be some discomfort.

I also accept that the area immediately after treatment will show a colour darker than that chosen – this darker colour will lighten over the following 5-7 days (the healing process varies from person to person depending upon many variables). I accept that should I accidentally pick, pull or knock the treated area then I could get gaps.

I confirm I will strictly adhere to the typed after-care instructions posted/handed to me and only use the after-care products advised by my technician. I understand that complications are possible, particularly if post-procedure aftercare instructions are not followed and if I get an infection post-procedure I will visit my Doctor immediately. If I have any questions or queries after the procedure I will telephone the technician to discuss.

I fully understand that every client is different so a time scale for the retention of lip pigment can not be guaranteed. I understand that colours will change with time. The skin tone of every client is different and colour should stay visible in the skin for several years (and in some cases indefinitely) but this can not be guaranteed.. The pigment will be present permanently but will not necessarily be visible. A re-touch procedure will be required between 12-24 months to keep the procedure looking fresh. This is dependent on age, skin type and colour chosen.

I understand that when my procedure has been completed the technician will provide me with the opportunity to discuss any immediate concerns and provide me with after care instructions that must be adhered to.

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Signature:
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Top Up Appointment
I confirm that nothing has changed medically or personally since having my last procedure: I agree to disclose any information in relation to the procedure and any changes that I wish to make.
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Signature:
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Date:
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Anaesthetic Used
CLIENT ADMINISTERED TO THEMSELVES
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Signed by Client:
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Date:
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Additional Comments
Additional Comments
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Aftercare advice
For further aftercare advice please click here
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I agree to the websites privacy policy & T&C's
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