ROX BROWS - MICROPIGMENTATION CONSULTATION RECORD

Section 1

Micropigmentation (known as Semi Permanent Make Up) is a procedure that can only be performed by a trained and qualiﬁed specialist using approved equipment to implant coloured pigments into the skin using sterile needles. The treatment requires your full consent and medical history disclosure so that your consultant can conﬁrm you are a suitable candidate for the proposed treatment.

Your consultant will discuss the beneﬁts and risks of the proposed treatment, and record the consultation on this form. This form will then be used for reference on subsequent visits.

It is essential that you clearly mark any areas that you require further clariﬁcation or discussion to ensure that you are fully informed before a treatment commences.

Your consultant will discuss the procedure in full, including what it will involve, the healing process and further treatment where necessary. You will then be provided with written aftercare information for you to keep and refer to during the healing process.

Terms of your treatment:

• You have chosen a cosmetic procedure that is not medically necessary.

• Micropigmentation is an art process -‐ not an exact science -‐ and cannot guarantee an exact colour result due to how colours can heal diﬀerently in all individuals. The selected colour will be darker immediately after treatment. This darker colour should exfoliate and lighten within 7-‐14 days after treatment. Lighter colours fade faster than darker colours, and all colours can change with time.

• You may be required to return for additional treatments before your procedure is deemed complete. The payment for any additional work (if applicable) will be agreed prior to procedure commencing. Additional treatments cannot be performed for 4-‐8 weeks (depending on treatment) after initial procedure. This is in order to allow the initial treatment to heal fully.

• Your consultant will use a treatment plan to record the colours you have chosen, anesthetic used, needles used and pre and post treatment photographs. This information will be held securely in your consultation record.

• The skin type of every client is diﬀerent and colour should remain visible in the skin for several years (in some cases indeﬁnitely). The pigment will be present permanently but not necessarily be visible. A re-‐touch procedure will be required periodically to keep the procedure looking fresh.

• After each treatment some swelling or redness may occur. In some cases there may be bruising. Your consultant will recommend solutions to reduce these symptoms. Throughout the treatment you may experience some discomfort, but your consultant will reassure you throughout and endeavor to make you feel comfortable.

• Pigments used in Semi-Permanent Make Up contain iron oxides, and diﬀer to the inks used in tattooing.

• It is essential that is you ever have an MRI or a CAT scan you should inform the radiologist that you have had micropigmentation. You may experience some tingling in the treated area.

• You must adhere to aftercare instructions given to you after your treatment. This is very important and will ensure you aren’t vulnerable to infections after leaving the clinic. You must let the treated area heal properly. Avoid picking, plucking or knocking as this will hinder the healing process and could make the treatment appear uneven thus requiring further work.

• Be aware that skin altering procedures such as plastic surgery, implants and injectables may alter the positioning and placement of where the pigment has been implanted

Section 2

Your consultant will follow guidelines as outlined in section 15 of the Local Government Act 1982. In addition to this, it is recommended that your consultant use aseptic conditions throughout the treatment.

PHOTOGRAPHIC CONSENT

I consent to photographs being taken BEFORE, DURING, and AFTER my procedure. I agree to these potentially being used for social media and online.
Consent for social media usage can be revoked entirely, please just let me know.

PATCH TEST/WAIVER: (Please tick the circle for A or B on form)

(A) I understand that a skin test can determine whether I will suﬀer a reaction to the products used for ROX BROWS within 24 hours, but that it is inconclusive whether I will have an allergic reaction at any time in the future. I therefore waiver my option to an allergy test and wish to proceed with treatment.

(B) I have undergone or been oﬀered an allergy test prior to my initial treatment and I therefore release the ROX BROWS consultant from any liability related to allergic reactions to the applied pigments or other products used after the procedure, or at a later date.

TITANIUM DIOXIDE DISCLAMER

Titanium Dioxide is an ingredient present in colours used for micropigmentation. The majority of colours only present minute traces of Titanium Dioxide, but lighter formulations and white pigment contain larger quantities. Titanium Dioxide is required to make light and vibrant colours. It is important that you understand that lasers used in permanent hair removal can permanently alter the colour of the SPM treatment, and this cannot be rectiﬁed with further treatment.

By having the micropigmentation procedure you must accept that you must inform your laser specialist that you have had this procedure.

CONSENT

I understand that my consultant will be in direct contact with me in relation to the micropigmentation treatment. This treatment involves the use of disposable needles and that all other equipment is sterilized before use, all surfaces involved in the process are protected and that gloves will be worn at all times by the consultant during the treatment.

I hereby consent to receiving a micropigmentation treatment. My consultant has explained the terms and conditions of the treatment and I have fully understood these. I hereby give written consent to the consultant who is a trained specialist, to carry out the treatment of my choice as requested by me on this consent and treatment agreement.

MICROPIGMENTATION AFTERCARE ADVICE

Should you have any queries, or you feel your treatment is not healing as explained on the day or in this aftercare sheet, please get in contact with your consultant. Do not panic if the area treated becomes red or swollen, or that the colour initially looks dark and intense – this is normal and the colour will fade during the healing process.
Additional treatments cannot be undertaken until the area has completely healed. A four to six week healing time is required before any further treatment can proceed. Your consultant will advise you at this point if they feel more time is required.

Key Healing Points:

· You will go through 3 healing phases:

Heal – brows will appear darker and defined due to the skin drying.
Heel/flake/scab – the dead skin on top is ready to come away from your tattoo, DON’T PICK!
Fade to implanted colour – the colour will develop over a few weeks’ time, for new clients there will be patches where the skin has not taken as well – this will get topped up on your follow up appointment in 4-6 weeks.

· DO NOT GET WET. Avoid water touching the treated area until it is fully healed; keep fully dry for the healing period of 7-10 days.

· Avoid using the gym, sauna and steam room for around 10-14 days until the scabs/ flakes have come off as moisture, including sweat, can affect the pigment settling in the skin.

For brows
·        Dry heal, do not use any products on brows, do not touch them for the healing period of 7-10 days to avoid infection.

·        During the healing process do not pluck, wax or use cosmetics on the treated area.
Do not pick or pull the treated area as it will result in a loss of pigment.

·        Once the treated area has completely healed (approximately one week) consider using a waterproof sunblock if going outside, to stop the colour fade. Strong chemicals or Glycolic acid/peels of any kind may cause pigments to fade and/or lighten. Contact your consultant if in doubt.

· You may notice some whiteness or blanching around the area, this is normal and will subside within 12 hours. If you find any lymphatic fluid or blood weeping from the treated area you should gently clean the area using a saline or cool boiled water and gauze, blotting gently to remove all moisture.

· Should you wish to apply make-up it is suggested you purchase new products to avoid cross contamination. After the initial scabbing has sloughed away you will see a different hue to the colour implanted.

Important information:

· Colour refresh – To keep your treatment looking at its best, it is recommended that you have a colour boost procedure every 12 months for facial procedures.

· Giving blood – The Red Cross has suggested that you do not give blood for 6 months after treatment.

· MRI Scans – This procedure shows as an artifact on the scan. Some clients may experience a slightly tingling sensation, please notify your radiologist of your treatment.

· Injectables – Dermal fillers can alter the shape of your eyebrows or lips.

· Laser hair removal – This can cause colour change, particularly around the lip area. It is important to advise your LHR Consultant that you have had micropigmentation.
The colour change after laser treatment cannot be rectified with further treatment