Cosmetic Tattoo

←

Let us do this part

Today's Date:

Wed Mar 12 2025 05:39

Practitioner:*

Treatment Type:*

Location on body:*

Treatment Price:*

The Cosmetic Ink Clinic
72 High Street
Milton Regis
Sittingbourne
KENT
ME10 2AN

Please read and answer

Do you have Flu like symptoms?*

IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.

Eaten?*

Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.

Permanent Makeup Procedure Agreement*

I understand and accept that:

• Having discussed and chosen the shape, colour and agreed the service to be provided with my therapist, I am happy with the proposed finished result.
• I understand that the skin will be slightly swollen immediately following treatment which can give the illusion of shape and this will decrease in size over the next few days as the treatment area heals.
• I understand that the colour will fade by 30-50% over the next 4-6 weeks.
• I understand that I will need a top up in 4-8 weeks depending on treatment in order for the the result to be as long lasting as possible, this top up appointment is included in the full price of treatment and without this appointment my treatment will not be complete.
• I understand that it is my responsibility to ensure I am available to attend for a top up treatment and there will not under any circumstances be a refund for missing this appointment.
• I understand that this treatment will require regular top ups at approximately 12-18 month intervals in order to maintain long lasting results.
• I am aware no warranty or guarantee has been made to me regarding my permanent makeup/correction procedure, and I accept that the final result cannot be guaranteed, and therefore no refunds will be given for this treatment under any circumstances.
• I am aware that there is a possibility of discomfort, slight bleeding, swelling, and allergic reactions to the procedure/pigments/dyes used.
• Cosmetic Tattooing is considered permanent, however the pigments used for this treatment are designed to fade over time.
• A tattoo can only be removed with a surgical procedure, and any effective removal may leave permanent scarring or disfigurement. Saline and Laser removal techniques are options to fade/remove cosmetic tattoos however there are no guarantees that this treatment can remove an unwanted cosmetic tattoo completely.
• I understand that I must inform my cosmetic tattoo technician verbally of all medications being taken by me, even if I have written this on the Confidential Medical History forms. For example, pain control medication such as aspirin may cause the blood to thin, and excessive bleeding may occur.
• I understand i must be free from drug and alcohol use or any other substances at the time of all treatments
• I understand the cosmetic tattoo treatments must not go ahead if i am pregnant or breastfeeding.

• I understand following this treatment there is a risk of scaring, blood poisoning, localised infection, allergic reaction, localised swelling around treatment site, bruising, misplacement or migration of pigment, risk to loss of eye lashes (eyeliner/lash enhancement treatments)
• Misplacement of the dye can occur, under very rare circumstances, requiring excision of the misplaced dye. In extreamly rare cases, there may be permanent loss of eyelashes (eyelash enhancement/liner treatments).

• I understand Titanium dioxide is present as an ingredient in many pigment colours in small traces, but present in larger quantities in lighter formulations and white pigment. Regardless of what is stated by the manufacturer on the label of the bottle, no one can guarantee that white (an essential component in many colours) is not going to be mixed in pigment. Therefore, by my signature on this form, I acknowledge that I understand that my decision to proceed with a micropigmentation/permanent makeup procedure will prevent me having any future laser treatments in the area of my micropigmentation/permanent makeup. If considering laser hair removal you should inform the laser specialist that you have micropigmentation/permanent makeup as laser can drastically change the colour of the treated area if in direct contact.
• I have been made fully aware of the pre-care and aftercare requirements and have been informed of any risks/hazards associated with this treatment verbally and in writing (as above) and I understand maintenance and care of treatment once completed is my sole responsibility in order for the outcome to be a success.
• I have received a skin sensitivity test and skin analysis to reduce risk of adverse reactions and have given my signed permission for said skin sensitivity test (included in consultation form).
• I have read and signed all forms regarding medical history and skin conditions, and I am fully aware of all that the treatment involves.
• I have read this statement prior to the permanent makeup procedures being performed, and have been given the opportunity to attain reasonable understanding of this Agreement, including the opportunity to ask questions, either by written, verbal or manual communication prior to the signing of this document.

• I hereby consent to the application of micropigmentation/permanent makeup. I have read and fully understand all the points listed in this procedure consent form. I accept full responsibility for any complications that may arise during or following the treatment. I hereby give my written consent for a micropigmentation/permanent makeup procedure to be applied as requested by me on this consent and procedure agreement.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Legal Name:*

Pronoun:

Chosen name:

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

Gender:

Phone #:*

Email:

Signature:*

Sign above or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:

Photo ID

Please take photo(s) of your government issued photo IDs and related paperwork.