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Consent & treatment record

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RECORD CARD

Reference

Clients name:

Address:

Phone number:

Moblie number:

Email:

STRICTLY PRIVATE AND CONFIDENTIAL - TO BE FILLED IN BY THE CLIENT

Full Name:

Tel No:

DOB:

Age:

Occupation:

Preferred method of contact:

TODAY'S PROCEDURE

AGREED PRICE: £

Appointment date

Appointment time

Deposit status

CLINICAL PHOTOGRAPHY I consent to clinical photographs for my confidential treatment record. I separately consent to identifiable photographs being used for promotional/marketing purposes. I do not consent to promotional/marketing use of my photographs.

CLIENT CONFIRMATION BEFORE TREATMENT I confirm the information I provide in this form is complete and accurate to the best of my knowledge. I understand I must tell the practitioner about changes to my health, medication, pregnancy/breastfeeding status, allergies, skin condition or recent procedures before treatment. I understand the practitioner may postpone, modify or refuse treatment where they consider it unsafe, unsuitable or outside their competence. I have had the opportunity to ask questions and understand that signing this form does not remove my statutory rights.

PATCH TESTING FOR ALLERGIES - PATIENT TEST / WAIVER

I chose to waiver my option to an allergy test and wish to proceed with the treatment:

Yes No

I understand the skin can determine within 24hrs if I will have a reaction to the products, but that it is inconclusive regarding whether I will have an allergic reaction at any time in the future.

I have undergone or been offered an allergy test prior to my initial treatment and thereby release the technician from any liability to an allergic reaction to applied or other products used after the procedure, or at a later date.

TITANIUM DIOXIDE

NICKEL

I HAVE READ AND UNDERSTOOD THIS SECTION (Please tick as appropriate)

MATERIAL RISKS & EXPECTED HEALING

Temporary redness, swelling, tenderness, bruising, dryness, flaking, itching or minor bleeding may occur.

Pigment may heal lighter, darker, warmer, cooler, uneven or patchy; colour retention varies between individuals.

More than one session may be required. Perfect symmetry and exact colour matching cannot be guaranteed.

Allergic or sensitivity reactions, infection, scarring, pigment migration, granuloma or other inflammatory reaction are uncommon but possible.

Cold sores may reactivate following lip treatment in susceptible clients.

Eyeliner treatment may cause temporary watering, swelling or irritation; contact lenses may need to be removed.

Future laser, MRI/CAT imaging, peels, injectables, surgery, sun exposure, medication and skin changes may affect the appearance of pigment.

I understand these are recognised risks/limitations of SPMU and that an undesirable outcome does not by itself mean the treatment was performed negligently.

TERMS OF YOUR TREATMENT

I understand that Semi Permanent Make Up {SPMU) is a process with healing variables, therefore, healed colour cannot be guaranteed.

I understand that SPMU is a multi- treatment process with colour being implanted slowly and carefully over a period of time and layering process.

My chosen colour will look much darker when initially implanted but should exfoliate and lighten within 7 /14 days.

I understand that additional work cannot be undertaken within 4-8 weeks of the first appointment, in order to allow the skin to fully heal.

I understand that all colours will fade and alter with time. To keep fresh appearance, a re-touch procedure will be required every 6 -12 months. Fade is dependent on age, skin type, medication, colour chosen and sun exposure.

I agree that my specialist will use a treatment plan to keep a log of the colours we have chosen, along with my pre and post treatment photographs. This information will be held securely in my confidential file.

I understand that after each treatment, the treated area may swell or show redness and, in some cases, bruising. My specialist will recommend how to take care of this. I may experience some discomfort but my specialist will reassure me throughout and will endeavour to me feel comfortable.

I understand that if I have an MRI or CAT scan, I must let the radiologist know that I have had a SPMU procedure. I may experience a slight tingling in that area.

I have been given aftercare instructions and I understand that I must adhere strictly to these instructions.

I am aware that any sun exposure, future skin altering procedures, such as plastic surgery, peels, implants, and /or injectables, may alter the appearance of my procedure. My technician has discussed likely outcomes with me and recommended a treatment plan, prior to any work being agreed and undertaken.

DESIGN, COLOUR & TREATMENT APPROVAL The proposed shape/design has been shown to me before pigment implantation and I approve it. The proposed pigment colour has been discussed with me and I approve the selection. I understand natural facial asymmetry and skin characteristics can affect the healed result. I understand the practitioner may stop the procedure if there is unexpected bleeding, swelling, skin reaction, equipment/product concern, client distress, or any other safety concern.

Client initials confirming design/colour approval:

Practitioner initials:

TO COMPLY WITH THE TATTOOING ACT - SECTION 1

Are you over 18?

Are you pregnant or breastfeeding?

Do you feel fit and well to have this procedure?

TO COMPLY WITH THE TATTOOING ACT - SECTION 2

Do you have any allergies or has any allergic reactions to medicine or products e.g. Latex, plasters, nickel etc.?

Have you or are you having any injectable or fillers or chemical peels?

Have you any imminent holiday plans?

Have you any keloid scarring?

Do you suffer from epilepsy and had a seizure in the past 2 years?

Do you suffer from haemophilia?

Do you knowingly have any infectious diseases or mitral valve prolapse?

Do you knowingly have hepatitis?

Do you suffer from shingles ?

Do you suffer from cold sores, fevers, blisters or skin disorders such as psoriasis or Eczema, Acne?

Do you have diabetes?

Do you have any respiratory problems?

Do you have problems with wound healing?

Do you take blood thinners or anti-inflammatory ?

Do you take Antabuse?

Do you take roaccutane ?

Do you have high or low blood pressure?

Do you wear contact lenses/ suffer from glaucoma?

Are you currently taking any medication?

Are you 5 weeks pre or post radiology/chemotherapy treatment? (if yes medical consent must be given)

Are you allergic to local anaesthetic?

If answered yes to any of the above, please give details:

MEDICATION / CONDITION DETAILS & PRACTITIONER DECISION

Relevant medication/condition:

Medical advice/clearance requested?

Decision:

CLIENTS DECLARATION - TO BE COMPLETED PRIOR TO COMMENCING TREATMENT

Have you had this treatment before?

Are you a Model for Trainee?

Date:

Were you happy with the procedure?

Please state were and when last procedure was carried out:

Which clinic previous treatment was carried out:

Date of treatment (approximate):

Please give reason:

FOR MODELS HAVING PROCEDURE DONE BY TRAINEES

I understand this procedure is being carried out by a trainee and not a trained specialist but with the guidance of a specialist technician/trainer. I understand that there are no guarantees as to the success or longevity of my treatment.

PRIVACY & HEALTH INFORMATION Explicit consent where relied upon: I expressly consent to Shibui Cosmetics processing the health information I provide for the purpose of assessing treatment suitability, providing SPMU treatment, aftercare and maintaining my treatment record. I understand that data-protection consent can be withdrawn, although this does not affect processing already carried out and some records may need to be retained under another lawful basis.

Privacy notice version/date provided to client:

Method:

FINAL INFORMED CONSENT I have read and understood this form, including the risks, limitations, healing process and aftercare requirements. I have disclosed relevant medical information and have had an opportunity to ask questions. I understand there are no guarantees as to the success or longevity of my treatment. I accept these terms and hereby give my written consent for a trained specialist to carry out the course of treatment of my choice. I hereby give consent for my personal details to be held for up to 10 years.

Additional notes

Client Signature:

Print name:

Date / time:

Consent & treatment record

Open your consent record

Practitioner only - patch test evidence

TITANIUM DIOXIDE

NICKEL

FOR MODELS HAVING PROCEDURE DONE BY TRAINEES