Personal Information Consent Form Personal Information Consent Form 2017 Step 1 of 6 16% Personal InformationDate* Name* First Surname Address Street Address Address Line 2 Town/City County Postcode Date of birth* Contact number*OccupationEmail* How did you hear about us?* Procedure(s) you are interested in?Explain in as much detail as possible your desired result, including shape, colour, definition. Is there a specific technique you wish us to perform? Previous Permanent MakeupHave you had permanent makeup before?*YesNoWere you pleased with the end result? If not, please explain the reason why.Area of the face treated?N/ABrowsEyesLipsDate of treatment. Is there any residue colour still visible?YesNoN/AHave you had permanent makeup removed?*YesNoN/AIf yes, which method was used?LaserLiquidOtherN/AArea of the face?BrowsEyesLipsN/AHow many removals?Date of last removal? Medical InformationAre you under the care of a physician, doctor or specialist for any short or long term illnesses or investigations? If so list the relevant details of conditions, for the last 12 months.In the last 6 months have you undergone any medical or surgical procedure?Are you planning any medical procedures?Are you taking any prescribed medication (including herbal or self-prescribed) either long or short term?Do you or have you suffered from any skin conditions/complaints? (tick if yes) Acne Dermatitis Eczema Moles Psoriasis Keloid scarring Vitiligo UVA discolouration: liver spots, solar lentigines, melasma Do you have any scars, moles or undergone surgery in the area to receive treatment?YesNoHave you undergone any laser or cosmetic eye surgery in the last 3 months?YesNoHave you ever had an allergic reaction?YesNoIf yes, how did it manifest?Have you ever had a reaction to anaesthetics or had an abnormal healing response?YesNoPlease tell us of any medications that you take currently or have used during the last 3 months.For example are you taking/undergoing/about to undergo/using: Antibiotics, Antabuse in the last 6 months Anti coagulants incl Warfarin Antidepressants Aspirin Asthma medication Chemotherapy High blood pressure medication Hormone therapy (contraception HRT, IVF or other) Ibuprofen in the last 7 days Prescribed pain killers or regular pain killers Immune suppressants Insuline Radiation Therapy Roaccutane in the last 6 months Steroids Warfarin/ blood thinners Topical steroids or prescription creams Do you have or have you ever had any of the following conditions? (tick if yes) Alopecia Anaemia Anaphylaxis Asthma Auto Immune Disease Bleeding Disorder Cancer Depression Diabetes 1 or 2 Epilepsy Eye disorder(s) Glaucoma Eye infections Haemophilia Heart condition Hepatitis Herpes Simplex High blood Pressure HIV Positive Hyper pigmentation Iron Deficient Lupus Scar heavily or keloid TB/Lung Disease Facial AestheticsHave you had any of the following? Permanent implants (lip/cheek) Dermal fillers Botox Chemical peels or laser treatment RF, HIFU or Ultrasound facials If yes, when was date of your last treatment. Have you had any of the treatments listed above or other facial aesthetics? If yes, please give details of area.If you have any of the above treatments booked, when is your next appointment? Terms and ConditionsCancellation Policy (it is not our intention to offend, so please be aware of our terms and charges for missed/failed appointments) 72 hour cancellation notice (Upshire) 7 days cancellation notice (Harley Street) We allocate significant time to each appointment, including follow-up appointments, which generate expenses whether attended or not. In all instances we apply a £100 cancellation charge where required notice is not given. This is not discretionary upon circumstance. Retouches are scheduled with the same cancellation terms and costs. All offers, discounted or model bookings: - MUST GIVE 7 DAYS NOTICE TO RESCHEDULE OR CANCEL WITHOUT CHARGE. Where this does not happen the full cost of the appointment will be charged. This is not a discretionary charge or dependent upon personal circumstances. - FOLLOW UP APPOINTMENTS must be attended no more than 5 weeks post original procedure. After this time our scheduled Additional Appointment fees will be applied. This is not a discretionary timescale. Annual colour boosts are recommended every 12 months. Procedures fade and shrink over time, we recommend you attend before excessive fade out occurs to avoid a new treatment being necessary. If medication or medical conditions are not declared on this form that prevent treatment from proceeding we will impose the full treatment cost.I have read, understood and agree to the cancellation policy.* Yes I have read, understood and agree to follow the pre treatment information and aftercare instructions provided.* Yes I understand Upshire is in a rural location within private grounds and have taken the time to read the location and parking instructions provided.* Yes Patient Consent I understand that permanent makeup is a process in which the skin is broken in order to place coloured pigment into the dermal layer of the skin and that Perfect Makeup will aspire to achieve the best possible outcome. No guarantees are made to the final colour of the pigment, length of time it remains visible through the skin, poor saturation or loss of pigment. I understand that one retouch appointment is included in the cost of the original procedure. All further appointments are paid for individually. Colour boosts do not include a retouch. I agree upon and accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure approved before treatment commences. Perfect Makeup will keep a treatment record of colours chosen. In all instances of asking Perfect Makeup to make a decision I accept I am responsible in approving the procedure. I understand that Perfect Makeup is not responsible for the safety and final colour of semi-permanent pigment previously applied by other technicians. Retouch of initial treatment must be attended 4 to 6 weeks later. I understand the same cancellation and late arrival policy applies. Further, if I do not return within 6 weeks of the initial treatment it is deemed that I am satisfied with a single procedure and that I will pay for any further procedure taken thereafter in line with the published price list. I understand that no money will be refunded to me should I decline the second treatment. Lip Procedure: I understand that if I suffer from Herpes Simplex Virus I could have an outbreak. To minimise the possibility of this it is my responsibility to contact my doctor to discuss obtaining Aciclovir, Zovirax or other anti-viral medication. I understand this is an invasive procedure and carries with it possible consequences including but not limited to pain, swelling, redness and bruising during and post treatment. Possible scaling and scabbing. I understand that the colour will appear too dark until healing finishes. I confirm I will adhere to the aftercare instructions to avoid complications. If complications do arise and there is any sign of infection post-procedure I will visit my Doctor immediately. Perfect Makeup suggest you consider your healing procedure as a wound and attempt to keep conditions as sterile as possible. I release the Perfect Makeup from all liability related to any subsequent adverse reaction to applied pigments, treatment or aftercare. I understand that photographs of the treatment area(s) before and after every procedure will be taken to form part of the client history and agree to this being carried out. I agree to my photo’s being used for marketing purposes. I confirm that I am over 18 years of age. I am not pregnant, breast feeding or under the influence of alcohol. I have answered the medical questionnaire to the best of my knowledge and have not knowingly withheld any information. I have received the post treatment advice, the contents of which have been explained to me and I will follow the advice given. I hereby agree to hold harmless and release from any liability Perfect Makeup Ltd, Ashlene McCormack as well as any directors or employees of the company for any condition or result, known or unknown that may arise as a result of any treatment. Please note we take photos for our records, we do not use full face without specific consent. I hereby give consent to perform this and all subsequent treatments with the above understood.I have read the terms and conditions above and give my consent.* Yes NameThis field is for validation purposes and should be left unchanged.