Luxury beauty treatments in the heart of London

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New Client Form

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Personal Details

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Date of birth *

GP's Details

Doctor's Name

GP Address

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Treatment

What treatment are you looking to receive?

PMU Treatment *

Medication Declaration

Are you currently taking any medications?

Medications in last 6 months? *

Yes

No

Medications

Medication Medical Agreement *

I understand that I will not take any of the following medication 2 days prior to my treatment

Pregnancy

Are you currently pregnant? *

Yes

No

Are you currently breastfeeding? *

Yes

No

Dental Treatments

Have you ever had a dental injection to numb your gums? *

Yes

No

Prior to dental procedures do you receive antibiotic medication? *

Yes

No

Do you have difficulty breathing or rapid heartbeat with a dental injection? *

Yes

No

GDPR Consent

GDPR means we need to ask your permission for things – we never spam and you're always in full control of your data.

Consent Required

We would love to show your transformations on our social media channels and on our website. By ticking this box, you consent to that. You can revoke consent at any time.

By ticking this box you give us permission to occasionally send you marketing communications via text or email – this is how we let our favourite clients know when we run special offers, discounts and last-minute appointments.

Medical Health Form

Your safety is our primary focus. We make everyone complete an in-depth medical health form ahead of their first treatment so that we can check that you are suitable to receive Permanent Makeup Procedures. It is vital that we have a complete understanding of your medical history so that we can treat you in the safest way possible.

Please fill in the following questions to the best of your ability and don't leave anything out! If a question doesn't apply to you, just click Not Applicable.

Medical Conditions – Brain or Nerve Conditions

Medical Conditions – Nervous and Mental Disorders

Medical Conditions – Cancers & Tumours

Medical Conditions – Cancers & Tumours *

Cancer (in last year)

Blood or Bone Marrow Cancer (e.g. Leukaemia, Lymphoma or Myeloma)

Targeted Cancer Treatments (that affect immune system e.g. Protein Kinase Inhibitors or PARP Inhibitors)

Tumours or growths of Cysts (in last year)

Haemangioma ("strawberry marks") on site

Chemotherapy, Antibody Treatment, or Radiation Within 1 Year

Not applicable

Medical Conditions – Endocrine

Medical Conditions – Endocrine *

I confirm that the information I have submitted is accurate, and have not omitted anything from my medical history which may cause adverse effects to my treatment outcomes.

Full Name *

Client Declaration Date *

Client Declaration Signed *

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General Consent and Procedure Permit

I hereby authorise AA BEAUTY to perform upon myself micro-pigmentation. If any unforeseen condition arises in the course of the procedure(s) I further request and authorise them to use their full judgement and do whatever they deems advisable and necessary in the circumstances.

I understand that micro-pigmentation is an advanced form of tattooing.

I accept responsibility for determining the colour, shape and position of the enhancement as agreed during the course of my consultation.

I understand that in order to proceed with the micro-pigmentation procedure I must have completed a sensitivity test for pigment and numbing agent and have had no adverse reactions to either of these.

General Consent and Procedure Permit Confirmation *

Yes

No

I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs.

I am aware that a sensitivity reaction to anaesthetics can occur and accept all responsibility if allergic response occurs.

I fully understand and accept that non-toxic pigments are used during the procedure and that the enhancement achieved may fade over the course of 1-3 years. Even though the colour has faded, the pigment will stay in the skin indefinitely and may leave a light residue of colour.

I accept that the highest standards of hygiene are met, and that sterile disposable needles are used for each individual client, procedure and visit.

I understand and accept that new enhancements usually require multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I need to return for the control procedure, which is included in the initial price. I understand and agree, that if I do not return for all the treatment sessions as set out in my treatment plan, that I accept total responsibility for the final result.

I understand that the control procedure, if required, must be performed 1-3 months after the initial procedure and that after the said 3-month period,that I will be charged an additional fee for any further treatment. I understand that a 4-week period must pass from the initial pigment application to the control procedure, to allow the procedure site to fully heal. I will book the appointment when it is convenient for both parties.

I understand that the pigment may migrate under the skin, however this is a rare occurrence.

I understand that micro-pigmentation is an invasive procedure and the infusion process can be uncomfortable.

I understand that loss of any eyelashes during the healing of eye enhancements will result in new eyelash growth over a 4-month period and that eyelash loss is rare and minimal.

I understand that in rare cases that corneal abrasion can occur during eyeliner procedures.

I am aware that the result of the procedure is determined by the following: Medication Skin Characteristics - i.e. dry/oily/sun-damaged, Natural skin undertones , Alcohol intake and smoking, General stress, A compromised immune system, poor diet, post procedure care

I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which usually subsides within 1 - 4 days dependent on lifestyle. In some cases bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited for up to two weeks following the infusion process.

I understand that immediately after the procedure the enhancement can be 30 to 70% darker than the desired result and can take between 4 -14 days to lighten. I understand that the true colour will be visible 4 weeks after each application, and that the colour may vary according to skin tones, skin type, age and skin conditions. I appreciate that some skins accept colour more readily than others and no guarantee of an exact effect or colour can be given.

I am aware that if I have had a previous outbreak of cold sores/herpes and receive a lip enhancement I may have an outbreak again following the procedure. I have been made aware that anti herpes medication is available over the counter or on prescription and has been shown to prevent or minimize such outbreaks.

I am aware that that if I have had a previous eye disorder or eye infection and receive an eyelash enhancement, the disorder may reoccur again. I agree to use the correct medication to prevent such a disorder reoccurring.

I am aware that even though my vision is not affected by micro-pigmentation eye enhancements I may wish to have someone drive me home.

I understand that I may experience dry lips for up to 2 weeks following micro-pigmentation lip enhancement.

I understand that there are few effective methods for pigment removal. Laser and chemical removal have proven successful, however are a process.

I agree to inform any medical professional of my micro-pigmentation enhancement if I require a MRI scan.

I agree to make any technician who is conducting laser or IPL treatments close to my enhancement, aware that I have micro-pigmentation so that he/she can adapt his/her treatment plan accordingly.

I understand that a week before my menstrual cycle (if applicable) my body will be at its most sensitive.

I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. I understand that infection and possible scarring can occur if I do not adhere to the said instructions.

To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done. I am at least 18 years old. I will not be not under the influence of drugs or alcohol at the time of the proceedure.

For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s).

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE MICRO-PIGMENTATION OF MY OWN FREE WILL.

I have read and understood the above information.

General Consent Full Name Confirmation *

General Consent Confirmation Signature *

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