JAKLINE STUDIO PERMANENT MAKE UP Client Medical Health Form for Semi-Permanent Tattoo Name and Surname Age Phone Email General Information about SPM Procedure: Clients' health information and consent form is to be filled prior to the procedure The procedure of SPM (semi-permanent makeup) is the implantation of pigment into the upper layer of the skin, using a disposable needle and SPM machine. One needs 2 sessions (5/6 weeks apart) to achieve a desired result (which also depends on the skin type and lifestyle). Consultation is free and is an important part of the procedure. Home care is given to the client and adherence to it is the duty of the client. The pigment will appear 30-50% brighter right after the treatment. The result is evaluated after 4-5 weeks. SPM professional is obliged to perform the treatment in accordance with health and safety regulations, inform the client about stages of the procedure, ensure to be in touch with the client during the healing time. Jakline Studio is fully licensed by Malta Health Department. Have you received chemotherapy or radiation in the last 6 months? NoYes If you are pregnant, nursing or under 18 years of age, procedure CANNOT be performed, NO EXCEPTIONS List (if any) medications you take for thinning the blood Do you have any known drug or food allergies? If so, please list and explain Do you have an allergy to any of the following? LatexVaselineCrayonsGlycerinMetalLanolin BeeswaxHair DyesLidocaineBenzocaine Have you ever had a cold sore, shingles or herpes simplex I or II? NoYes If you answered yes to the question above, please obtain an antiviral prescription from your doctor for prevention, JAKLINE STUDIO Permanent Make Up will not be liable for an outbreak of the above due to the procedure. Are you currently under regular care of a physician for a chronic issue? NoYes If yes, please detail the issue Physician's Name Issue Do you have any of the following conditions? Please select Hair LossSensitivity to CosmeticsProlonged BleedingDiabetes IDiabetes IITrichotillomaniaArtificial Heart ValveLow Blood PressureEpilepsyHigh Blood PressureHemophiliaCirculatory ProblemsFainting Spells or DizzinessAlopeciaHypertrophic/Keloid ScarsAnemiaLiver Disease/HepatitisHIVAcneHumors, Growths, CystsCancerDermatitis/RosaceaVitiligoHealing ProblemsThyroid DisturbancesPsoriasisImmunocoprimisedBotox/Filler Injections Contraindications for semi-permanent procedure: Liver disease - high risk of infection Pregnancy/Nursing Compromised skin near brow area (Current injury or active acne) High blood pressure Auto-Immune Disease Thyroid/Grave's Disease Cancer (At any stage including remission) Any other medical condition that causes slow healing or a high risk of infection I confirm that I have read and understood all the questions in this questionnaire I confirm that I have read and understood all the post procedure homecare instructions I confirm that I am aware that no re-touch, alteration or claim can be made to the procedure before a minimum period of four weeks from the procedure I understand that if after 7 days irritation/redness/infections occurs, this is not related to the procedure Signature Removal Treatment? Yes Information and Agreement for the Removal-Lightening Procedure: I agree to undertake the procedure of pigment lightening. I am aware that the treatment is done by using non-medical laser or remover product. The therapist determines which is appropriate at this moment. I understand that the result depends on skin condition (possible scarring from previous SPM treatments), structure of the pigment, depth of the implantation. I agree to photograph before and after. I am aware that the treatment takes up to 30 minutes. I am aware that pigment may (in some cases) appear brighter at first. I am aware that the homecare given to me is an important part of the treatment. Date Procedure Removal signature
