Online health waiver system- paperless, safe and permanent storage.

MEDICAL HEALTH FORM AND DISCLOSURE AGREEMENT

NAME: *Please enter your name.

DATE OF BIRTH: *

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ADDRESS: *

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PHONE: *Please enter your phone number.

EMAIL *Please enter your email.

SEX ID *

MALE

FEMALE

Please select at least one choice above.

SURGERY: *Please enter your answer here.

MEDICAL CONDITIONS *Please enter your answer here.

CURRENT MEDICATION *Please enter your answer here.

ALLERGIES *Please enter your answer here.

DO YOU USE *

SUNBEDS

LIP FILLER

EYEBROW/LASH TINT

ANTI WRINKLE INJECTIONS

CONTACT LENSES

NONE OF THE ABOVE

Please select at least one choice above.

We legally have the right to refuse clients below the age of 18yrs and can request proof from any client of whom we challenge. Are you over 18? *

Yes

No

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Have you had PMU before? *

Yes

No

Please select at least one choice above.

If YES, please confirm that you understand that we cannot guarantee satisfactory results if we tattoo over previous work. This is because we cannot be certain if the pigment/products used were EU approved or US approved or if body art tattoo ink was used. This also applies to any correction and/or removal work of a previous PMU procedure that you may have undergone. Do you understand?

Yes

No

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Do you suffer from haemophilia? *

Yes

No

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Are you pregnant or breast feeding? *

Yes

No

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Are you under the influence of alcohol and/or drugs? *

Yes

No

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Do you carry the Hepatitis C/AIDS or HIV Viruses? *

Yes

No

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Are you 5 weeks or less post chemo/radiotherapy treatment?(If YES, you will be expected to provide a doctor's note) *

Yes

No

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Do you suffer epileptic seizures? *

Yes

No

Please select at least one choice above.

Are you on a prescription of blood thinning medication? *

Yes

No

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Are you 6 months or less post course of Roaccutane and/or Antabuse prescription? *

Yes

No

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Do you suffer from the cold sore herpes simplex virus? *

Yes

No

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Do you confirm that, to the best of your knowledge, that any medication you are taking or any courses of prescription medication which you’ve concluded, do not affect the way that your skin heals/bleeds/bruises/swells etc? *

Yes

No

Please select at least one choice above.

If you have refused or not received a sensitivity patch test, please understand that Charlotte Taylor Semi Permanent Makeup reserves the right to refuse treatment. Alternatively , you can choose to waive the sensitivity patch test and sign for this on the disclosure and consent agreement.Do you understand? *

Yes

No

Please select at least one choice above.

Have you undergone any laser tattoo removal procedures within the past 6 months on the area which you wish to receive a tattoo at this appointment? *

Yes

No

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I UNDERSTAND THAT A SKIN TEST CAN DETERMINE WITHIN 24 HOURS IF I WILL HAVE A REACTION TO THE PRODUCTS, BUT THAT IT IS NOT INCONCLUSIVE REGARDING WHETHER I WILL HAVE A REACTION AT ANY TIME IN THE FUTURE. PATCH TEST COMPLETED? *

Yes, 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 to applied pigments or other products used after the procedure, or at a later date

No, I choose to waiver my option to an allergy test and wish to proceed with the treatment

Does not apply for scalp treatment

Please select at least one choice above.

Treatment: *

EYES

LIPS

BROWS

SCALP

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Do you suffer with any physical, mental impairment or disability that may affect your ability to decide whether or not to have a procedure done. *

Y

N

Please select at least one choice above.

I authorise the technician stated above to perform the procedure(s) listed above on myself. *

Y

N

Please select at least one choice above.

I confirm I have read and understood the sensitivity patch test instructions before having a permanent cosmetic procedure done, neither the technician or clinic shall be held liable for any adverse reaction that I may experience as a result. *

Y

N

Please select at least one choice above.

We want to manage your expectations, so please understand and appreciate that the results you get at the end of your procedure may vary from each individual. This depends on a number of factors such as the pigment colour blended with your natural skin tone, the shape and position of your facial features, any medication that you are taking, your skin characteristics (dry, oily, sun damaged, thick), the PH balance of your skin, diet, alcohol intake, smoking and any post-operative care treatment (if applicable). If the end results are not what you expected, you have no automatic rights to request for any changes (unless the technician agrees). *

Y

N

Please select at least one choice above.

I accept responsibility for determining the colour, shape and position of eyebrows/eyeliner/lipliner/beauty mark or other as agreed during the course of my consultation. *

Y

N

Please select at least one choice above.

The application procedure for permanent cosmetics has been explained to me either before or on the day of my appointment, and I accept that non-toxic pigments will be used during the procedure(s) and multiple applications may be required to achieve the desired colour. For this reason, I understand that I may need to return for a retouch procedure after the first application. *

Y

N

Please select at least one choice above.

The retouch mentioned above can be carried out between 4-12 weeks after the first application. I agree to book my appointment within this period. If the procedure is not earned in this period, I understand that I will be charged the appropriate fee in place at the time for the retouch procedure. *

Y

N

Please select at least one choice above.

I understand that once the pigments are tattooed into the skin the colour will usually fade over time. I accept the fact that even though the colour may fade, the pigment will stay in the skin indefinitely. *

Y

N

Please select at least one choice above.

I have been informed that sterile disposable needles and pigment containers are used for each individual client and procedure on each visit. *

Y

N

Please select at least one choice above.

Once a procedure is completed it is likely that you will experience some swelling, bruising and/or redness of the skin. This will usually subside in around 4-5 days. You should be able to resume your normal activities immediately following the procedure, although you are strongly advised not to use and cosmetics or products on affected area(s). If you have had an eye procedure, you may need to arrange for someone to drive you home. We would also advice you not to do any activities that would expose the affected area(s) to sun or cause your body to expire excessively. *

Y

N

Please select at least one choice above.

I understand that lip or eye procedures may stimulate any dormant viruses in the eyes, lips, mouth or surrounding areas (e.g herpes simplex, conjunctivitis). Any medication that I have or am currently using to treat a virus may affect the absorption of the pigment. I will consult my GP before having a procedure done, if I am unsure whether I should have the procedure. *

Y

N

Please select at least one choice above.

Once I have had the procedure done I have been advised that the true colour should be seen approximately 4-6 weeks after the procedure (although this is not guaranteed and varies depending on the factors set out in (9) above). *

Y

N

Please select at least one choice above.

I agree to follow the Aftercare advice that I am given. *

Y

N

Please select at least one choice above.

I consent to the taking of before and after photographs of my procedure(s) and I assign all intellectual property rights (including moral rights) in the photos to the technician that takes them, or to the clinic where the procedure is taken place. *

Y

N

Please select at least one choice above.

I consent that I have asked any questions that I need to ask my technician, to ensure that I fully understand the different aspects of the procedure before having it done. *

Y

N

Please select at least one choice above.

I am aware of the Charlotte Taylor Semi Permanent Makeup Privacy Policy and understand that personal information may be passed onto a third party if necessary. *

Y

N

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DATE *

Set Today

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SIGNATURE *

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