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Micropigmentation Consent Form & Health Assessment

Before signing, please review the PMU FAQs, contraindications, side effects, pre-procedure recommendations, and aftercare guidelines (see the PMU Tab) to fully understand treatment details.

Micropigmentation Health Questionnaire

Date
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Day
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Please answer the following questions about your health so that we can safely perform the procedure. All information is confidential.

1. Do you suffer from any chronic illnesses?
Yes
No
2. Do you have any allergies (latex, pigments, anesthetics, medications)?
Yes
No
3. Do you currently have or have you had any skin problems in the are of treatment? (psoriasis, eczema, acne, herpes)
Yes
No
4. Are you currently taking any medications? (steroids, retinoids, anticoagulants)
Yes
No
5. Are you pregnant or breastfeeding?
Yes
No
6. Do you have a tendency to form hypertrophic scars (keloids)?
Yes
No
7. Do you suffer from any of the following conditions?
Yes
No
Opciones múltiples
8. Have you undergone any cosmetic or medical procedures in the last 6 months? (chemical peels, Botox, dermabrasion)
Yes
No
9. Do you currently have any infections, inflammations, or irritations in treatment area?
Yes
No
10. Are you afraid of needles?
Yes
No
11. Is there anything else we should know before the procedure?
Yes
No

AUTHORIZATION FOR MICROPIGMENTATION DECLARATION

I declare that all information I provided is true and accurate. I understand that concealing any health information may increase the risk of complications during procedure. I Consent to the microblading procedure based on the information I have provided.  

1.       I am aware that the results have a minimum durability of 6 months and a maximum of 2 years, which varies according to the chosen technique, care and skin type of each client; and that will gradually clarify over time.

 

2.       I received recommendations and instructions after the procedure and I am aware of my psychological and health conditions; I do not fit into the list of ¨Risk clients¨ described by the professional during the consultation, so the professional is exempt from any responsibility for the reactions they may present.

 

3.       Since I am not a “risk customer”, I did not request an allergy test.

 

4.       I assume full responsibility for the procedure, I am responsible for following the corresponding care guidelines, therefore; the professional will not be responsible for problems caused by possible negligence on my part.

 

5.       The professional previously made a service design, which I approved; being of the recommended shape and color, and to my total liking and desire.

 

6.       I agree with the pigment color that was selected for the procedure, the shade of which is like my stated desire.

 

7.       I assume all responsibilities and consequences arising from my decision to perform micropigmentation.

 

8.       I also authorize you to photograph before and after with documentation; and that this material is used for scientific and marketing purposes. 

 

9.       Once the service was finished, in which I approved the design and checked the symmetry made; the professional is not responsible for possible failures resulting from the healing process; are necessary or not, subsequent touch-ups.

 

10.    I am aware that the micropigmentation procedure is characterized by being an extremely gentle technique, that is why the healing and pigment fixation process differs for each person, ranging between 6 months and 2 years.

 

11.    I am aware that after the first procedure; A touch-up must be carried out after 50 days, to consolidate and reaffirm the details of the first session, which guarantees a better result that can last over time; Since the professional has explained it to me previously, and I accept that this second procedure has an additional value that is canceled the day it is performed.

 

12.    I understand that retouching should not exceed 90 days; maximum should be in the range of 50 to 90 days; and that after 6 minus, it is no longer considered a retouch; but a new procedure. (called annual eyebrows).

 

 

I confirm that all information provided is accurate and complete. I understand that withholding health details may increase procedural risks. I consent to the microblading procedure and acknowledge assuming all associated risks. I have received, understood, and accept all terms stated, and sign this authorization accordingly.

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Contact Us!

407-715-3792


To book appointment or have any questions or inquiry simply call, text number listed above or send us a message.

Hope to hear from you soon.

Thank you!

 

We are located in Leesburg, Fl

2115- G citrus Blvd. Leesburg Fl 34748

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