Dawn Aldersn Permanent Makeup & Beauty Clinic Cnsultatin Frm: Name Cntact N Address Pstcde: DOB: Please read these statements carefully: Permanent csmetics are a frm f tatting als called Micrpigmentatin. Re-tuch prcedures are nearly always required fllwing the initial prcedure; please nte this is a tw stage treatment prcess, retentin hlds much strnger fllwing the retuch. A minimum healing perid f fur / six weeks is required befre a re-tuch prcedure can be perfrmed depending n age and skin type. A healed result can be seen 4-6 weeks after the treatment. Retentin f pigment depends n many factrs including, skin type, age f client, adhering t aftercare prcedure, lifestyle, sun expsure, medicatin and vitamins. On rare ccasins the pigment may migrate under the skin particularly if very ily based skin type r pen purs. Therefre the treatment will give a mre pwdered lk and may have less retentin. Old Scaring may act like dead skin fr the ink and ften times d nt hld pigment. Applicatin f permanent csmetics can be painful. The pigments will fade ver time which may vary with each client. Immediately after the prcedure, the pigment can be 30 t 50% darker than the desired result. There may be immediate r delayed allergic reactin t pigments. Hwever, allergic reactins are extremely rare. A negative allergy test result will nt guarantee that yu will nt have an allergic reactin. Allergic reactins t anaesthetics can ccur. Permanent csmetics cannt be applied t pregnant wmen r nursing mthers. Permanent csmetics cannt be applied t any persn under the age f eighteen. Infectins can ccur if aftercare instructins are nt fllwed crrectly. There may be swelling and redness fllwing the prcedure. Yu may experience minr bleeding. It is recmmended that clients receiving treatment fr eyeliner shuld have smene drive them hme. Crneal abrasin may ccur during eyeliner prcedures. Hwever, crneal abrasin is rare. Clients receiving lip prcedures wh have had previus prblems with cld sres/herpes may have an utbreak fllwing the prcedure. Anti herpes medicatin is available ver the cunter r n prescriptin and has been shwn t prevent r minimize such utbreaks. Lip prcedures may appear dry and flaky fr up t ne week fllwing the prcedure. If yu have an MRI scan within 3 mnths f yur permanent csmetics prcedure we recmmend that yu discuss this with yur dctr. Pssible scarring, incnsistency f clur and lss f eyelashes may ccur. It is nrmal fr the tp layer t flake ff, DO NOT PICK, as yu will rip ff the deeper layers f pigment with it and it will have n retentin. 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 1
Dawn Aldersn Permanent Makeup & Beauty Clinic What t expect straight after the prcedure: Day 1: Fr eyebrw treatments: the brws will appear slightly thicker and the clur will lk much strnger and maybe warmer due t the redness caused in the skin. Eyeliner: The skin rund the eye may appear swllen and red due t the stretching and implantatin f pigment int a sensitive area. Lip: will appear strnger in clur and swllen. The main swelling will subside within a few hurs as this is mainly due t the aesthetic applied. Swelling frm the prcedure will subside within 48 hurs. Day 2-4: The brws will appear 2 shades darker frm when yu left the clinic and clur may seem a little red still. Lips als will appear up t 50% darker / brighter then the finial healed result is actually ging t be. They may als feel rugh and dry. Day 6-10: nt all brws g thrugh the flaking prcess; sme clients can t even see the flaking. Brws may lk very light and patchy at this stage. The pigment will reappear in nearly all cases. Day 28-40: Depending n the client, this is the time when yu actually start t see the final result. Peple wh heal quickly and yung client can see their final clur by the 4-5 week mark, while mre mature wmen and slwer healers may have t wait 6-7 weeks t see the clur fully blmed back. As the mnths g by the pigment will appear sfter and lighter as it settles under the layers f skin. T prtect against fading use a sunscreen, avid sunbeds and cut dwn n vitamin C, Glyclic acid. This infrmatin is nt intended t alarm yu. Hwever, it is imperative that yu are infrmed f the risks invlved and that YOU FOLOWWING THE STRICT AFTERCARE INSTRUCTIONS. It is very imprtant that yu clsely review yur treatment that has been carried ut, especially at the retuch stage. If yu request a third fllw up treatment this will be chargeable and include a tray set up fee f 39 plus labur. A depsit f 50 is payable upn bking appintment. The depsit is transferable/ refundable nly if 14 days ntice is given t cancel r alter an existing appintment. After 14 days the depsit becmes nn refundable r transferable. I AGREE TO FOLLOW THE AFTERCARE PROCEDURES GIVEN TO ME DURING MY TREATMENT FOR BOTH MY INITIAL AND RETOUCH PROCEDURE. Name....Signature...Date..... Technician Name...Signature...Date... 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 2
Dawn Aldersn Permanent Makeup & Beauty Clinic Medical Health Frm Name: Cntact N Address: Date f Birth: Occupatin: Name f Dcter: Surgery: Please answer all the fllwing questins: Have yu taken any f the fllwing in the last 2 days; Aspirin, Ibuprfen, Cumadin, Alchl? Have yu received chemtherapy r radiatin treatment in the last year? List any medicatins yu have been taking in the last 6 mnths Allergies: have yu ever had an allergic reactin t any f the fllwing? Lanlin Latex Rubber Vaseline Medicatin Paints Crayns Metals Hair dyes Lidcaine Drugs Fds Glycerine Anaesthetics r Adrenaline (which nes) Other allergies (list) Have yu r have yu ever had any f the fllwing? Tick all f the fllwing that apply: Abnrmal Heart Cnditin Mitral Valve Prlapse Rheumatic Fever Pacemaker Haemphilia Diabetes Epilepsy Fainting Spells r Dizziness Thyrid Disturbances Glaucma Stmach Ulcers Cancer Tuberculsis Strke Palpitatins Hepatitis Pregnant r Nursing in the 12 mnths Alpecia Recent Hair Lss Chapped Lips Trichtillmania Cld Sres (herpes simplex) Heart Murmur Artificial Heart Valves Anaemia Prlnged Bleeding High Bld Pressure Lw Bld Pressure Circulatry Prblems Liver Disease Kidney Disease Tumurs, Grwths r Cysts HIV Prsthetic Hip r Jint Cataracts Blurred Visin Dry Eyes Eye Infectin present Watery Eyes Cntact Lenses Eyelid Surgery Date f last eyelash/ eyebrw tint 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 3
Dawn Aldersn Permanent Makeup & Beauty Clinic Gre-Tex Implants/Silicne Injectins Other Tatts Fat Transfer Injectins Btx Injectins Cllagen Injectins Hypertrphic Scars Chemical r laser peel within 6 mnths Kelid Scars Sensitivity t Csmetics Bruise r Bleed Easily Use f Sun bed Scar Easily r healing prblems Retin A within 6 mnths Crtisne within 6 mnths AHA preparatins within last 2 weeks Acutance within 6 mnths I cnfirm that the abve infrmatin is crrect Client Name....Signature...Date... Technician Name...Signature...Date... 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 4
Dawn Aldersn Permanent Makeup & Beauty Clinic General Cnsent and Prcedure Permit Clients Full Name Address I hereby authrise Dawn Aldersn f Dawn Aldersn Permanent Makeup & Beauty Clinic t perfrm upn myself the fllwing prcedure(s) If any unfreseen cnditin arises in the curse f this prcedure(s), calling in her judgement in additin t, r different frm thse nw cntemplated, I further request and authrise her t d whatever she seems advisable and necessary in the circumstances. I accept respnsibility fr determining the clur, shape and psitin f the permanent csmetic prcedure as agreed during the curse f my cnsultatin. I understand that an allergy test des nt guarantee that I will nt have an allergic reactin t the pigment. We cannt accept respnsibility if the treatment area des nt numb. Each individual is different accrding t the skin type. Fr all prcedures a cream r gel tpical anaesthetic is used. These prducts are perfectly safe, and can be purchased ver the cunter frm any chemist. I fully understand and accept that nn-txic pigments are used during the prcedure and that the csmetic enhancement achieved may fade ver a perid f 1-3 years. Even thugh the clur has faded the pigment will stay in the skin indefinitely. Fr eyeliner prcedures yu will be asked t keep yur eyes clsed thrughut the numbing perid. If fr sme reasn the anaesthetic gets int the eye, yu must advise yur technician at nce. It is nt harmful t the eye althugh yu will experience sme stinging and slight discmfrt. The cream will be remved and yur eyes will be immediately flushed with a sterile saline slutin. It is then safe fr the technician t reapply the anaesthetic. NOTE: If yu experience stinging in the eyes and d nt infrm yur technician immediately, the anaesthetic may numb the eyeball, and a pssible crneal abrasin may ccur. This can result in a temprary streaming and light sensitivity f the eyes. Yu may be unable t pen yur eyes and each time yu blink it may be painful, and temprary blurry visin may ccur. Crneal abrasin, hwever, is rare. I have been infrmed that the highest standards f hygiene are met and that sterile dispsable needles and pigment cntainers are used fr each individual client, prcedure and visit. I understand and accept that each prcedure is a prcess requiring multiple applicatins f pigment t achieve desirable results, and that 100% success cannt be guaranteed during the first prcedure. I understand that this is why I will need t return fr a retuch prcedure. I understand that a retuch prcedure will be perfrmed 1-3 mnths after the initial prcedure and that after a 3-mnth perid I will be charged an additinal fee fr any further wrk. I understand that it is my respnsibility t bk the appintment at a time cnvenient fr bth parties. 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 5
Dawn Aldersn Permanent Makeup & Beauty Clinic The result f the prcedure is determined by the fllwing: Medicatin, Skin Characteristics - (dry, ily, sun-damaged and thickness), Natural skin undertnes - (blending with chsen pigment), Persnal ph balance f skin, which changes frm visit t visit, Alchl intake and smking, adhering t Pst Prcedure care treatment. Upn cmpletin f the prcedure there may be swelling and redness f the skin, which will subside between 1-4 days. In sme cases bruising may ccur. Yu may resume nrmal activities immediately fllwing the prcedure hwever, using csmetics, excessive perspiratin, steamy shwers and expsure f the sun t the affected area shuld be limited. I have been advised that the true clur will be seen 1 mnth after each prcedure, and that the pigment may vary in clur accrding t skin tnes, skin type, age and skin cnditins. I understand that sme skins accept pigment mre readily than thers and n guarantee t an exact effect r clur can be given. I am aware that the lip prcedures may stimulate any drmant virus such as herpes (cld sres). I am infrmed that eye prcedures may stimulate drmant eye disrders r eye infectins, and that sme medicatin can prevent absrptin f the pigment. I agree t fllw all pre-prcedure and pst-prcedure instructins as prvided and explained t me by the technician. I cnfirm that I have received cpies f all the relevant aftercare instructins. Being f sund mind and bdy, I hereby release any and all respnsibility. I accept any and all respnsibility myself fr any cnsequence that might stem frm my decisin t have any permanent csmetics prcedure perfrmed by Dawn Aldersn Fr the purpse f dcumentatin, I als cnsent t the taking f befre and after phtgraphs f said prcedure(s) fr recrd purpses and fr use in presentatin prtflis. I CERTIFY THAT I HAVE READ AND HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND I ACCEPT FULL RESPONSIBILITY FOR THESE AND OR OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE PERMANENT COSMETIC/TATTOO PROCEDURES WHICH IS TO BE PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT AND PROCEDURE PERMIT. T my knwledge I d nt have any physical, mental, r medical impairment r disability that might affect my well being as a direct r indirect result f my decisin t have the prcedure dne at this time. I am ver 18 years f age. I am nt pregnant. I am nt under the influence f drugs r alchl. I have read an understd the abve infrmatin. Client Name......Signature...Date... Technician Name...Signature...Date... 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 6
Dawn Aldersn Permanent Makeup & Beauty Clinic Cnsultatin Check List & Treatment Plan TREATMENT CARRIED OUT Date: Pigment Clurs Used Brand Needle Selectin Prcedure ntes Agreed fee Depsit Paid Retuch Fee Technician Name...Signature....Date... Retuch Treatment Any change in medical histry since initial prcedure? Client Signature...Date...... Pigment Clurs Used Brand Needle Selectin Prcedure ntes Technician Name...Signature....Date... 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 7
Dawn Aldersn Permanent Makeup & Beauty Clinic Dctr s Cnsent Frm (if required) Fr The Attentin f Dctr Dear Sir, Yur patient cntacted me with a view t receiving a permanent csmetic prcedure. Permanent csmetics are an advanced frm f tatting in which pigment is implanted int the dermis f the skin using needles. A fully qualified technician trained t Nuveau Cntur standards, which are apprved by the Sciety f Permanent Csmetic Prfessinals will carry ut the treatment. As my client has indicated a medical cnditin during pre-prcedure cnsultatin, it wuld be preferable that yu cnsider the implicatins and give yur cnsent fr the treatment. If yu feel that the prcedure wuld have n detrimental effect t the health f yur patient, culd yu please cmplete the details belw? Surgery Name Address Dctr s Name I understand that (patient s name) is t receive permanent csmetics which is a frm f tatting. I have cnsidered my patient s medical cnditin and feel that this prcedure will have n detrimental effect t his/ her health. Signed 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 8
Dawn Aldersn Permanent Makeup & Beauty Clinic Pre Prcedure Advice Permanent csmetic prcedures nrmally require multiple treatment sessins. Fr best results, clients will be required t return fr at least ne retuch prcedure, usually between fur and six weeks after the initial prcedure. Be prepared fr the clur intensity t be significantly sharper and darker immediately after the prcedure. This will subside and becme lighter as the tissue heals. This prcess can take up t ten days. Advice fr all permanent csmetic prcedures Since delicate skin r sensitive areas may be swllen r red, it is advised nt t make scial plans fr the same day. Please wear yur nrmal makeup t the saln n the day f the prcedure. Please infrm yur technician if yu have taken aspirin, Ibuprfen r Cumadin within the tw days leading up t prcedure. D nt discntinue any medicatin befre cnsulting yur dctr. D nt drink alchl the night befre yur treatment. A patch test will be perfrmed unless waived upn request. Eyebrw Prcedures Any waxing shuld be perfrmed at least 48 hurs befre the prcedure: Electrlysis n less than five days befre the prcedure. Eyebrw tinting shuld nt be undertaken fr tw weeks prir t the prcedure. Eyeliner prcedures Any eyelash tinting r eyelash perming shuld be carried ut n sner than 1 week befre r tw weeks after the prcedure. D nt wear cntact lenses during r immediately fllwing the prcedure. Remember t bring yur glasses. Yu may resume wearing yur cntact lenses as sn as yur eyes feel cmfrtable. (This is nrmally 24 hurs after the prcedure). Yu may have sme swelling, as a safety precautin, we recmmend that yu have smene available t drive yu hme. Lipliner/Clur If yu have a histry f cld sres (herpes simplex), we advise yu t cntact yur dctr t btain the prper prescriptin medicatin t prevent such utbreaks. Alternatively, btain herpes medicatin fr example Zvirax frm yur lcal chemist and use ne week befre and ne week after yur prcedure. This can help minimise an utbreak. Permanent csmetic prcedures d nt cause cld sres, hwever if yu carry the virus, it lays drmant in the bdy and can be arused by the prcedure. Lip wax r bleaching treatments shuld nt be undertaken fr at least a tw week perid preceding yur permanent csmetic prcedure. 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 9
Dawn Aldersn Permanent Makeup & Beauty Clinic PERMANENT COSMETIC AFTER CARE INSTRUCTIONS FOR EYELINER Prper care fllwing yur prcedure is necessary t achieve the best results. Keep in mind that in many cases, sme unevenness f clur is t be expected. This is the purpse f the re-tuch visit. Please review the fllwing directins and refer t them as necessary. If during the healing prcess yu have any questins r cncerns, please cntact yur technician. Fr the first day: Ice packs prtected with a clth may be applied as necessary t reduce swelling. Yu may experience the fllwing fr 72 hurs: Eyelashes may stick tgether, particularly vernight. Puffy eyelids. Tenderness. Redness r bruising arund the eyes. Dryness and itchiness in the treated area. Swelling. Daily Care t fllw fr at least ne week r until yur prcedure has fully healed: Always wash yur hands befre applying the after care healing balm. Apply a minimum f 3 times daily, using a cttn bud. Prevent crss-cntaminatin f yur healing balm by using a clean cttn bud fr each eye. We recmmend yu use a gentle facial cleanser t clean the face during the healing perid. Keep hair away frm the prcedure site t prevent any infectin. Sme itching is nrmal. DO NOT PICK, PEEL OR SCRATCH the treated area r the clur may heal unevenly and yu risk scarring and infectin. Allw the wund t flake n its wn. N makeup shuld be applied fr 72 hurs after the prcedure. A new mascara must be used after this 72 hur perid. D nt expse the healing skin t direct sunlight, tanning beds, Jacuzzis, saunas, salt water, chlrinated pls, direct shwer spray, ht water, skin creams r intments ther than what yu have been instructed t use fr tw weeks fllwing yur prcedure. If the area gets wet, gently pat dry using a clean tissue. Remember, yur selected clur will be strnger and mre sharply defined immediately after treatment but as the healing prcess ccurs the clur will sften and lighten. Lng Term Care Use a gd sunscreen. Sun expsure will fade yur permanent csmetics. If yu are planning a chemical peel, MRI scan r ther medical prcedure, please infrm yur dctr f yur permanent csmetics. Please infrm the Natinal Bld Service if yu dnate bld, as yu may nt be eligible t give bld fr a year pst prcedure. 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 10
Dawn Aldersn Permanent Makeup & Beauty Clinic PERMANENT COSMETIC AFTER CARE INSTRUCTIONS FOR EYEBROWS Prper care fllwing yur prcedure is necessary t achieve the best results. Keep in mind that in many cases, sme unevenness f clur is t be expected. This is the purpse f the re-tuch visit. Please review the fllwing directins and refer t them as necessary. If during the healing prcess yu have any questins r cncerns, please cntact yur technician. Fr the first day: Ice packs prtected with a clth may be applied as necessary t reduce swelling. Yu may experience the fllwing fr 72 hurs: Flaking. Tenderness. Dryness and itchiness in the treated area. Swelling and redness. Daily Care t fllw fr at least ne week until yur prcedure has fully healed: Always wash yur hands befre applying the after care healing balm. Apply a minimum f 3 times daily, using a cttn bud Prevent crss-cntaminatin f yur healing balm by using a clean cttn bud fr each applicatin. We recmmend yu use a gentle facial cleanser t clean the face during the healing perid. Keep hair away frm the treated site t prevent any infectin. Sme itching is nrmal. DO NOT PICK, PEEL OR SCRATCH the treated area r the clur may heal unevenly and yu risk scarring and infectin. Allw the wund t flake n its wn. N makeup shuld be applied fr 72 hurs after the prcedure. D nt expse the healing skin t direct sun, tanning beds, Jacuzzis, saunas, salt water, chlrinated pls, direct shwer spray, ht water, skin creams r intments ther than what yu have been instructed t use fr tw weeks fllwing yur prcedure. If the area gets wet, gently pat dry using clean tissue. Remember, yur selected clur will be strnger and mre sharply defined immediately after treatment but as the healing prcess ccurs the clur will sften and lighten. Lng Term Care Use a gd sunscreen. Sun expsure will fade yur permanent csmetics. If yu are planning a chemical peel, MRI scan r ther medical prcedure, please infrm yur dctr f yur permanent csmetics. Please infrm the Natinal Bld Service if yu dnate bld, as yu may nt be eligible t give bld fr a year pst prcedure. 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 11
Dawn Aldersn Permanent Makeup & Beauty Clinic PERMANENT COSMETIC AFTER CARE INSTRUCTIONS LIPLINER & SHADING Prper care fllwing yur prcedure is necessary t achieve the best results. Keep in mind that in many cases, sme unevenness f clur is t be expected. This is the purpse f the re tuch visit. Please review the fllwing directins and refer t them as necessary. If during the healing prcess yu have any questins r cncerns, please cntact yur technician. Fr the first day: Ice packs prtected with a clth may be applied as necessary t reduce swelling. If yu suffer with cld sres at present r anytime in he past use an anti herpes medicatin fr example Zvirax, five times daily. Cntinue use fr the next 6 days Yu may experience the fllwing fr 72 hur: Flaking. Tenderness. Dryness and itchiness in the treated area. Swelling and redness. Daily Care t fllw fr at least ne week until yur prcedure has fully healed: Always wash yur hands befre applying the after care. healing balm > Apply as many times in a day as yu feel necessary, using a cttn bud minimum f 3 times daily, using a cttn bud. Prevent crss-cntaminatin f yur healing balm by using a clean cttn bud fr each applicatin. We recmmend yu use a gentle facial cleanser t clean the face during the healing perid and n makeup shuld be applied fr 72 hurs after the prcedure. Keep hair away frm the prcedure site t prevent any infectin. Sme itching is nrmal. DO NOT PICK, PEEL OR SCRATCH the treated area r the clur may heal unevenly and yu risk scarring and infectin. Allw the wund t flake n its wn. D nt expse the healing skin t direct sun, tanning beds, Jacuzzis, sauna, salt water, chlrinated pls, direct shwer spray, ht water, skin creams r intments ther than what yu have been instructed t use fr tw weeks fllwing yur prcedure. N kissing and if the area gets wet, gently pat dry using clean tissue. Avid eating spicy and salty fds and try t drink thrugh a straw. D nt pick the epithelial crust. Allw it t flake n its wn. Remember, yur selected clur will be strnger and mre sharply defined immediately after treatment but as the healing prcess ccurs the clur will sften and lighten. Lng Term Care Use a gd sunscreen. Sun expsure will fade yur permanent csmetics. If yu are planning a chemical peel, MRI scan r ther medical prcedure, please infrm yur dctr f yur permanent csmetics. Please infrm the Natinal Bld Service if yu dnate bld, as yu may nt be eligible t give bld fr a year pst prcedure. 12 Gargrave Rad, Skiptn, Nrth Yrkshire, BD23 2LP Page 12