Online Form Procedure Consent Form For Semi-Permanent Make-Up Date of the treatment Customer full name D.O.B. Address Postcode Mobile number Email Procedure(s) interested in: Medication and Medical Information Are you currently under the care of a doctor or hospital specialist? YesNo If yes,please list the relevant details of your Doctor and Condition: Please check all medical conditions that apply to you: PregnantBreast feedingHyper pigmentationScar heavilyHaemophiliaDiabetesHepatitisTB,Lung diseaseUndergoing Radiation therapy or ChemotherapyCancerInfectious diseaseLupusHIV PositiveVeneral DiseaseFever BlistersAsthmaIron DeficientAnaemiaRespiratoryEye DisorderSkin DisorderMitral Valve ProlapseHerpes SimplexCold SoresDry Eye SyndromAlopeciaEpilepsyFainting AttacksBotoxFace liftThyroidAuto immune disease Other (provide details) Please check if you are taking any of the following medications: AccutaneInsulinBlood ThinnersSteroidsAnabuseAspirineAnti-CoagulantHigh Blood Preassure Other (provide details) Please check if you have any of thefollowing allergies: LidocaineAnaesthetic MedicineLatexLanolinMetalsFood Other (provide details) Do you have any imminent holiday plans? YesNo Do you have or are you planing to have any injectables, fillers or chemical peels? YesNo Do you have any tattoo or semi-permanent/ permanent make up already? YesNo I understand the importance of my accurate 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 respnsibility to advise my specialist. Allergy (Consent/Waiver) Form 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 during and after the procedure. I understand that all needles and machine parts 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 centre. I agree to pay the sum agreed at the end of my first treatment when I am satisfied with my procedure. I understand that All Semi-Permanent Cosmetic Procedures are Multi-Session Processes.An initial application is incomplete until after a follow-up appointment ,which MUST BE scheduled 4-8 weeks after your initial appointment (and no more than 8 weeks).There is my responsibility to make an appointment in time for free touch-up. 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 understand that micropigmentation is not an exact science and every client heals differently that I may require additional work (3rd touch-up) which I understand is chargeable. I confirm I will strictly adhere to the typed after care instructions posted/handed to me and only use the after care products given/advised to use by technician I fully agree to photographs being taken prior to,during and after procedure (which will be kept on file and not used for any other purpose,unless I agree below) Agree to all above I agree for my photos to be used to promote treatment on social media (facebook/instagram/salon website) YesNo IMPORTANT! There is additional charge for the (£50) follow-up appointment after your initial application and it should be performed within 8 weeks of the initial application. If you do not return in the agreed time scale it is deemed that you are happy with single procedure. Any additional touch--ups are chargable depends of needs and products usage (from £ 50) Any touch-ups done after 6 months from initial treatment are treated as color boost and the price is 50% of oryginal full price. Agree to all above DEPOSITS AND CANCELLATIONS We will require a 20% deposit on all bookings. The deposit is non-refundable but will be deducted from the charge which is to be paid at the end of the first appointment. We will need 48 hours notice to reschedule appointments. Failure to give at least 48 hours notice will result in the deposit being fortified and You will need to pay new deposit to make another appointment. There is 48 hours cancellation notice. Failure to give at least 48 hours notice will result in cancellation fee of £30, which will be require to be paid to make another touch-up appointment. Fee is NON-REFUNDABLE. Agree to all above