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

I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that 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 and accept 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 may leave a light residue of colour.

I accept that the highest standards of hygiene are met, and that sterile disposable needles 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 I need to return for a control procedure that 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 additional fee for any procedures. I understand that a control procedure takes place 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 may migrate under the skin, however this is a rare occurrence.

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

I understand that loss of any eyelashes during the healing 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 that in rare cases that corneal abrasion can occur during 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 dependent 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 to 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 skin tones, skin type, and 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 I have had a previous outbreak of cold sores/herpes 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 minimize such outbreaks.

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

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

I understand that scar camouflage procedures require skin colour-matching tests 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 a MRI scan within a 3 month period of receiving the procedure.

I understand that a week before my menstrual cycle (if applicable) my body will be at its most sensitive.

I agree to follow all 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 or indirect result of my decision to have the procedure done at this 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 the taking of “before” and “after” photographs of said procedure(s)

I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUSTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL.

I have read an understood the above information.

Client Name:…………………..……………Signature:…………………….…………Date:………

Practitioner Name:…………………………..Signature:………………………………..Date:……

    Please tick this box if you do not wish to be sent promotional offers or information.

   Please tick this box if you do not wish for your images to be used for advertising purposes (full face images will not be used unless further agreed by the client)

Pre Procedure Design to be completed on the day of treatment!

Subject to the agreed pre-treatment design template being shown to myself, as well as digital photographs being taken of the design template,

 I ……. ………………………………………………………………. (Clients Name) sign to say this is a true picture of the design requested.

 I also agree to have digital photos taken immediately after my treatment so that there is a true comparison between what was requested and what was delivered.

Signed: ……………………………………………………….. Date:…………………

On completion of the treatment.

I ……………………………am happy with the result of my enhancement.

Signed ………………………………………………Date……………….

New Data Protection Law (GDPR)

FM permanent Cosmetics Ltd & associated personal will NOT be able to contact you or hold your personal information or send appointment reminders and promotional offers without permission. Please could you sign below that you would still like us to be able to contact you and by which method. We would prefer to Email you, your reminder and notifications but we can text or call you if you prefer.

I would like to receive reminders by (please Circle preferred methods of contact)

Email    /     Text    /     Post     /    Telephone Call

I certify that I have read and fully understand the above information.

Clients Name:……………………….  …Signature:………………………………