Liana Nunes Micropigmentation Beauty Medical Clinic ...
CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR DARK CIRCLES CAMOUFLAGEName: ________________________ DOB: _________Best Phone Contact: ______________Address: ______________________Email: _______________________List any medications you have been taking in the past 6 months: ____________________________Have you received chemotherapy or radiation in the past year? ____________________________Have you ever had an allergic reaction to any of the following (please circle)?Latex Lanolin Vaseline Medication Metals Hair DyesFoods Lidocaine Paints Crayons GlycerinHave you ever had a cold sore? Yes NoIf yes, you must contact your physician for a preventative prescription capsule to prevent a cold sore.Have you ever had one of the following (please circle)?Retin-A in last 2 wks Anemia Sensitivity to cosmetics Prolonged bleeding DiabetesTrichotillomania Epilepsy Artificial Heart Valve Low Blood pressure High Blood PressureHemophilia HIV Alopecia Liver Disease Fainting spells or dizziness Circulatory Problems Hypertrophic scars CancerTumors, growths, cysts Botox/filler injections Thyroid disturbances Keloid scars Chemical/laser peel in last 6 wksHealing problems AHA’s in last 2 weeksHair Loss Hepatitis Do you scar easily? Pregnant or nursing?Do you bruise/bleed easily? I have received after care information and I’m fully aware of the aftercare procedures. Yes NoI fully understand the information provided above & confirm that all info provided by me is correct and truthful.Client’s Name ____________________Client’s signature ____________________Date ________Technician’s Name_________________ Technician’s signature _________________ Date ________MEDICAL & CORRECTIONAL TATTOOING PRE-PROCEDURE ADVICEWhy is pigment used?One of the most important factors in tattooing is the pigment choice. Pigments these days are medically certified and are used instead of ink. Ink in a normal body tattoo is a large molecule that is too big to travel through the layers of the skin, so it stays where it is implanted; into the dermal layer. Medically certified pigment is a much smaller molecule and is implanted into the same layer as ink, but it CAN travel through the layers of the skin. The lymph then comes along and processes it (breaks it down) and gets rid of it. Therefore, medical tattooing and semi-permanent makeup fade with time, varying between one and five years depending on age, body temperature, medication, skin type and aftercare. Colour boosts are necessary when the colour starts to change and fade. The pigments are safe, non-toxic and non-irritant.Pre-Treatment24 hours prior; do not take the following substances: Stimulants: Tea, coffee, soft drinks with caffeine or other substances containing stimulants.TreatmentThe number of sessions will depend upon the size of the area to be treated, the level of discolouration and how well the aftercare is adhered to.The treatment is NOT painful but can be tender. Anaesthetic can be used before and during the treatment to control the sensation.ContraindicationsScars and skin grafts must be fully healedKeloid scarring that has been treated with steroidsLaser can turn pigment dark so please make sure all laser treatments are finished before commencing Medical Tattoo treatment.Vitiligo needs to have been dormant for at least seven years otherwise a recurrence of spreading can be stimulatedRoaccutane use in the preceding six monthsPregnancy or breast feedingWe always need to leave a 30 days gap between the sessions.Anything I Need To Know Before I Begin Treatment?It’s crucial that your skin isn’t tanned at the time of the treatment. This is because the ‘prescriptive’ skin-shade pigments need to be blended to match your natural skin colour. If your tan fades, you’ll end up with a mismatch and your treated area will look darker than the surrounding skin.Will It Hurt?If your scarring has sensation, we make sure numbing agents are applied. Our clients describe the discomfort as no more than about 2 out of 10. And of course we’ll continually check to see how you’re feeling and make sure you’re comfortable.Will I Be Able To Go Back To Work Straight Afterwards?Absolutely. Typically the area around your treatment may be slightly red for 72 hours, but that should be the only after-effect.Do You Provide Aftercare?Yes Patient Photo Release Agreement for Liana NunesPatient Name ____________________________________I hereby consent to, and authorize the use by Liana Nunes of the specified Dark Circles Camouflage Tattooing photographs and/or video; that is, photographs taken before, during and after my procedure.Liana Nunes has explained that all the photos and/or videos will be clinically appropriate and tastefully presented.I have agreed on the photographs that Liana Nunes requests to be used and it is understood that these photos may be used on Liana Nunes website, google business, page social media accounts (Facebook, Instagram, Twitter), and in-office for demonstrational and promotional purposes. I understand that I am not entitled to compensation for these photos being used.Should I desire to revoke permission for their use in the future, I understand that I must notify Liana Nunes in writing and allow 30 days to accomplish this removal. I now release Liana Nunes, and anyone authorized by Liana Nunes, all personal rights and objections I have or may have to the above described uses of my photographs and/or videos. I have entered this release freely or voluntarily, and agree to be bound thereby.__________________ _______________________________DATE PATIENT SIGNATURE__________________ _______________________________DATE TECHNICIAN/WITNESS SIGNATURE I, __________________________________________________________, with address at ________________________________________________________ I am conscious that Dark Circles Camouflage has the intention of only CAMOUFLAGE, with a similar tone to your skin tone, that means we will try to make the dark area lighter and luminous.I compromise to send pictures of the area treated every 07 days if you are under Dark Circles treatment to our email liananunesbeauty@ or whatsapp +447803081847This is for us to follow the treatment correctly and check if the aftercare has been followed. In case you don’t send the pictures every 07 days for Dark Circles, we won’t be responsible if the results were not achieved accordingly.Client’s Name ____________________Client’s signature ____________________Date ________Technician’s Name_________________ Technician’s signature _________________ Date ________Dark Circles Camouflage After Care InstructionsUse a small quantity of Cicaplast Balm B5, La Roche twice a day to accelerate the skin healing process. Remove the excess with a towel or a kitchen roll. In the next 30 days you can only wash your face with neutral shampoo.NEVER:. No scratching, rubbing, picking the scabs, let them go naturally:. Take sun or sunbed or other aesthetic treatment on the area in the next 60 days;. It’s strictly prohibited of any cosmetic or oil on the treated area for the next 60 days;. Avoid sweating excessively, wear tight clothes. No swimming at pool, beach or Jacuzzi. Also no sauna.. AVOID WORKING IN THE GARDEN, dirt, pollutants from the environment may cause infections.. AVOID?seafood, salty and spicy foods.. AVOID?taking multivitamins with Vitamin A in, or using Retinol containing products on the areaREMINDER:Only after 2 days the swollen and redness will be disappeared.Just after the procedure, the dark circle area will be swollen and with pinkish colour. In the next two days the swelling will be disappeared and the area will start to be recovered. In the next seven days, the skin will have the appearance of 100% recovered but nothing can be put for 30 days.The final result will be only seen from 30 to 60 days.*** IT’S EXTREMELY IMPORTANT for the patient to send pictures of the area treated every 07 days to our email liananunesbeauty@ This is for us to follow the treatment correctly and check if the aftercare has been followed. In case you don’t send the pictures every 07 days we won’t be responsible if the results were not achieved accordingly.Any suspected alteration written here please contact us. ................
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