MEDICAL CONSULTATON

Please fill out the following Medical Consultation form in order to participate in any treatment with us. Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

Address & Postcode (Please fill in correctly, so we can ensure you have a patch test)

Birthday

Date of treatment

Previous Treatments

Have you had any previous Micoblading or permanent make up?

If yes, please upload a clear full-face photograph below.

Yes I've had previous treatment

Scars and Spots

Do you have any Scars, Moles or Spots within the eyebrow area?

If yes, please forward a clear full-face photograph to sheldonlouisecosmetics@gmail.com

Yes I have scars or spots

Upload File

Client Information

Known (potential) risks associated with Microblading and Micropigmentation:

scarring, blood poisoning, localised infection, allergic reaction to substances used, delayed allergic reaction to substances used, localised swelling around treated area.

The skin must not be in the inflammatory process or the process of healing and regeneration before each treatment. The following treatments are not recommended 30 days before the treatment: botox and fillers, fruit or milk acids, laser treatments, chemical peelings, exposure to strong sunlight.

Client Decleration

I declare that I give my full consent to the treatment being carried out by Sheldon Louise Regan practitioner. I confirm that potential complications, e.g. infection and swelling, for the procedure undertaken, aftercare instructions, factors that influence colour durability and colour reflection have/will be explained to me. A written aftercare sheet containing more detailed information has/will be given to me and I agree that it is my responsibility to read this and follow the instruction until the treated area has healed.

Tick to declare

I am aware that a retouch treatment in 4 - 6 weeks will be required (no later than 8 weeks or an additional charge will incur) and after it is healed, this will represent final results.

Tick to declare

I understand that for some people with extremely sensitive skin or capillaries located very close to the skin, additional retouch may be required at an extra charge and I accept this. For more information on this please see here.

Tick to declare

I confirm that the information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e. 18 years old) and that I am not currently under the influence of alcohol and drugs.

Tick to declare

Pre and Aftercare

I confirm that I have read and I am fully aware of Microblading/Micropigmentation pre care and aftercare advice -view them here

Privacy Policy

Under the current Privacy Policy, which can be viewed here it states that Sheldon Louise Regan seeks to collect and process my data. She requires explicit consent to collect this data as the advice and services she is to provide would be limited if I do not disclose.

I accept the Privacy Policy

I agree to photos being taken of my face and used on social media for advertising purposes

Patch Test

I am aware that I need to complete a patch test a minimum of 24hrs before the procedure.

Please note failure to complete the test could result in the cancellation of your appointment and loss of refund. If you have not received your patch test please contact me as soon as possible. (Make sure your address is filled in correctly above so we can send this out)

I agree that i will complete a patch test 24hrs prior to my treatment

Client Consultation Record

PLEASE READ THE BELOW INFORMATION

You have requested a Microblading/Micropigmentation treatment that involves minor breakage of the skin surface and this process may complicate some medical conditions. Please read the following information carefully, and if any of these conditions apply to you, you must declare them to the practitioner on the premises and discuss these matters. Same goes for any planned Microdermabrasion, Chemical Peels, Injectable Fillers (Botox).

SKIN CONDITIONS

Eczema this may make a person more prone to skin infections/ irritation

Psoriasis or other chronic skin conditions, excluding acne and disorders of pigmentation- same complications as eczema.

CIRCULATORY DISORDERS

Heart disorders some heart defects render individuals more prone to serious heart complications from any blood infections.

High/low blood pressure can cause lightheadedness and may be linked to other heart- circulation disorders.

Haemophilia and other bleeding disorders- as may result in poor healing.

PREGNANCY

Nursing mothers treatment must not interfere with the feeding process; also, any risk of infection for them is also a potential risk for their baby

Pregnancy the immune response may be affected by pregnancy; any infection may affect an unborn child

OTHER MEDICAL CONDITIONS

Epilepsy and persons who have experienced a seizure in the last two years. Medication may cause side effects and poor control of the condition may result in fitting/seizure during treatment.

Diabetes long term sufferers may have circulation problems that can reduce the healing properties of the skin; this can result in severe infection.

Auto-Immune Disease, HIV or other conditions or treatments causing immune- deficiency (e.g. cancer treatments- radio/chemo therapy) - are more prone to serious infections.

Hepatitis C may have circulation problems that can reduce the healing properties of the skin; this can result in severe infection.

Medication - Warfarin, Antabuse, Roaccutane; side effects may affect healing and recovery from treatment.

ALLERGIC RESPONSES

Allergies especially nickel allergy, may result in serious skin reaction from a small amount of metals sometimes present in applied products (inks etc.)

MEDICAL HISTORY OF KELOID SCARRING

People who have previously had keloid scars, are more likely to develop one at the

treated area.

OTHER CONSIDERATIONS BEFORE YOU UNDERGO TREATMENT

General treatment cannot be undertaken if you are under the influence of alcohol or drugs

Any other conditions any visible evidence of a cold sore or fever blister or a skin disorder, broken capillaries on the area to be treated

Any medical condition or use of prescribed medication must be stated below as it may be possible to proceed with the treatment with consent from a client or in some cases medical consent from the doctor.

INFORMATION ABOUT COLOUR DURABILITY

Durability of the colour depends upon many factors, and they can

be classified into 3 major groups:

Internal:

Sebum
Seborrheic dermatitis
Peeling of the skin
Keratoses
Excessive oiling of the skin
Various changes in the skin

External:

Facial treatments that regenerate the skin (chemical peeling, fruit acids, micro-dermal abrasion, laser treatments, mezzo-therapy etc.)
Excessive use of powder
Scars that represent the most aggressive way of mechanical injuries- appearance of acne, old PMU, laser removal etc.
Sun, solariums, lasers, light therapies.

Human:

Not following post-treatment after-care procedures.

I confirm that I have read and understand the above inforamation

Your Signature

Treatment Colour (We will fill this in for you on your treatment)