Scalp Micro-pigmentation Consent Form

Name

First NameLast Name

Age

Proof of age?

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

City

Postcode

Are you under the influence,drugs or alcohol, Antibuse?

FEMALE ONLY: Are you pregnant or nursing?

Do you have a communicable disease? HIV, hepatitis b,c, measles, semonela

Do you have any skin conditions?

Skin conditions (e.g. Rashes, eczema, infection, psoriasis, Keloid scarring, etc.)

If yes, please identify the condition.

Please tell about your medical history (e.g. DIabetes, Cardiovascular Disease, Epilepsy, haemophilia, Blood-related disease etc.)

If yes, please identify the condition.

Do you wear contact lenses or have Glaucoma

I understand that if I have an MRI or CAT scan I must inform the radiologist that I have had Micro pigmentation procedure. May experience a slight tingling in the treatment area

I agree that my specialist will use treatment plan to keep a log of the colours we have chosen, along with my pre and post treatment photographs, this will be held securely in my confidential file

I understand and am fully aware I am receiving a multi treatment and that the healed outcome may differ from my expectations.

I understand if I am to achieve the full potential from this micro pigmentation treatment I must keep up with aftercare advice I have been given and attend future maintenance appointments.

Do you have any allergies such as nickel, latex, plasters or medicines

If yes please identify,

I have been informed of the following aspects of the SMP procedure:

Purpose: I understand that the purpose of SMP is to improve the cosmetic appearance of my scalp by replicating the appearance of natural hair follicles.
Treatment Process: I have been provided with information about the SMP treatment process, including the application of pigments using specialized needles or equipment. I understand that multiple sessions may be required to achieve the desired results, and the number of sessions will be determined based on my individual needs and goals.
Risks and Side Effects: I understand that SMP carries certain risks and potential side effects, including but not limited to:

Temporary discomfort or pain during the procedure.
Temporary redness, swelling, or irritation at the treatment site.
Possible allergic reactions to pigments or anesthesia.
Fading or discoloration of pigments over time.
Infection or scarring in rare cases.

Results and Expectations: I understand that the results of SMP may vary depending on factors such as skin type, hair color, and individual healing processes. While SMP can create the appearance of fuller hair density and camouflage areas of hair loss, it may not replicate the exact look of natural hair follicles, and additional grooming or maintenance may be required to maintain the desired aesthetic.
Aftercare Instructions: I have received instructions on how to care for my scalp following SMP treatment, including recommendations for cleansing, moisturizing, and protecting the treated area from sun exposure and other potential irritants. I agree to follow these instructions diligently to optimize the healing process and minimize the risk of complications.

I acknowledge that I have had the opportunity to ask questions and seek clarification about the SMP procedure, and I have received satisfactory answers to my inquiries. I understand that SMP is an elective cosmetic procedure, and I consent to undergo treatment voluntarily.

I release [Clinic Name], [Practitioner's Name], and their respective agents, employees, and affiliates from any liability arising from or related to the SMP procedure, including but not limited to risks, complications, or unsatisfactory results that may occur as a result of the treatment.

I certify that I am of legal age and have the capacity to provide informed consent for SMP treatment. I have read this acknowledgment and waiver form in its entirety, and I understand and agree to its terms.

Client's Name

First NameLast Name

Client's Signature

Signed Date

Date

Scalp Micro-pigmentation Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver