INFORMED CONSENT FORM FOR PERMANENT MAKE-UP (MICROPIGMENTATION) PROCEDURE

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The purpose of the explanations in this form is not to worry you, but to enlighten you in a scientific framework about the before, during and after of the procedure and its possible risks. Please read carefully. If you have questions or points you do not understand, ask for help.

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1. Personal Information

 

Please fill out this section completely.

 

Name:

Surname:

Date of birth:

Gender:

Mobile number:

Signature:

 

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2. What is Micropigmentation Application and For What Purpose Is It Used?

 

Micropigmentation, also called permanent make-up, hair simulation, dermapigmentation, or “cosmetic tattoo process”, is a process similar to tattooing. It is the process of injecting very small dye particles with coloring properties into the upper layer of the skin with a sterile and disposable needle. It is implemented for the following purposes; in shaping thinned, damaged and short eyebrows, in reshaping eyebrows, in those whose eyebrows have fallen out due to medical reasons, in camouflaging blemishes and scars, in order to give a kohled look around the eyes, to reduce the need for make-up, to make lips appear clear and full, to make irregular lip contours, asymmetrical lips, In order to correct missing cracks and unclear lip contours, to give shape and naturalness to lips that have lost their shape after an accident or surgery, to color the lips, to correct asymmetries on the face, to make the hair appear shaved in cases of baldness due to hair loss, to make the skin look like its normal color in vitiligo (ala) disease. In order to imitate this appearance in cases where the nipple area (areola) is removed.

 

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3. What are the points to be considered before micropigmentation?

 

Please answer the following questions completely.

 

1. Do you have any infection in the application area or in your body?          YES         NO

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2. Do you have a chronic disease such as diabetes?          YES         NO

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3. Do you have an allergy, immune system or rheumatic disease?          YES         NO

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4. Have you had any surgery?          YES         NO

 

5. Do you have an active skin disease or do you have herpes attacks?          YES         NO

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6. Are you prone to bleeding?          YES         NO

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7. Are you positive for hepatitis (HBsAG, HCV) or AIDS (HIV)?          YES         NO

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8. Are you at risk of pregnancy, pregnancy or breastfeeding?           YES         NO

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9. Have you used any medication in the last week?          YES         NO

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10. Have you used blood thinners (aspirin, coumadin, etc.) in the last 3 days?          YES         NO

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11. Have you had any dermatological or aesthetic procedures in the last month?          YES         NO

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12. Have you tanned with the sun or a tanning bed in the last few weeks?          YES         NO

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13. If you have had this procedure done before, have there been any problems?           YES         NO

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WRITE BELOW THE SITUATIONS WHEN YOU ANSWERED YES TO THE QUESTIONS OR WOULD YOU WANT TO EXPLAIN OTHER THAN THE QUESTIONS.

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4. How is micropigmentation applied and what is the course of its effect?

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​Dyes produced for this purpose are applied to the upper layer of the skin with the help of micro sterile needles and a special device. This is applied to more superficial layers than a tattoo application. Superficial anesthesia can be applied to minimize the discomfort in the application area. Although the application time varies depending on factors such as skin moisture and elasticity and the person's sensitivity, it takes an average of 2-3 hours. It can be re-checked and retouched 3 or 4 weeks after the application. Although the dyes in permanent make-up vary depending on the person and exposure to external factors, they fade within 8 months to 2 years after permanent make-up applied to the face area, and within 2 to 6 years after micropigmentation applied to the hair area. The disappearance of the dyes does not occur suddenly, but gradually. Rarely, on some skins, the dyes may not be retained at all.​

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​5. What are the points to be taken into consideration after micropigmentation?

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• Care should be taken for 7-10 days until the healing process of permanent make-up and skin change is completed.

• Pigments should be covered with a thin layer of cream to protect the surface. If the person does not do this regularly throughout the entire healing period, a thick scar may appear due to pigment loss.

• Water should not touch the application area for 3 days. He/she should not sunbathe or go to the solarium for 2 weeks.

• Crusts formed on make-up application should never be removed.

• The recommended cream should be applied to the application area 3-4 times a day for a week.

• Peeling should not be applied to the area for 21 days.

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6. What are the Risks and Side Effects of Micropigmentation Application?

 

• Bruising, swelling, redness, pain, tenderness, swelling of hair follicles (perifollicular edema), itching, skin flaking, peeling, blisters, wounds, crusting, and bleeding may occur at application sites.

• Needle marks can be seen in the form of lines on the skin for 2-3 days.

• Infection may occur in injection areas or in general.

• Bruising, redness and minor bleeding may occur at the injection sites.

• There may be pain and tenderness in the applied area during and after the procedure, lasting up to 1 week.

• Allergic reactions (anaphylaxis, urticaria, shortness of breath) and infection may rarely occur.

• Light or dark skin color changes may occur on the skin after treatment.

• Depending on individual characteristics, scarring in the form of scar or keloid tissue may occur.

• If an unexpected effect develops, please contact our center.

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APPROVAL OF THE PERSON TO BE TRADED

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This procedure is not of vital importance like other cosmetic applications. Cosmetic procedures are non-medical interventions performed to reduce the negative effects on your skin such as wrinkles, lines, spots, scars, tattoos, capillaries, hair loss, sagging, stretch marks, unwanted hair, lack of moisture or unpleasant facial and body appearances. For reasons that are not fully understood, the success and permanence of the procedure may be shorter than expected. Additionally, no guarantee can be given regarding the results of the application. Any side effects that may occur will be evaluated by our center and improvement procedures (prescription adjustment, medical intervention, emergency intervention) will be carried out by our center's contracted doctor in the doctor's office. You can reach us at any time through the communication channels provided to you by our center.

 

• I was explained and understood that no cosmetic intervention, medical intervention or treatment could be performed on me without my permission.

• I have read the text above, which contains the information that must be given before MICROPIGMENTATION application. I understand the expected impact and risks of the method to be applied.

• In addition, other application options, possible consequences and risks were explained to me, written and verbal explanations were made to me about this procedure, necessary warnings were given and I understood it.

• I was in a position to ask questions about the trading options to be applied and their risks. My questions and concerns were discussed and answered to my satisfaction.

• It was stated to me that visual material samples (such as photographs) could be taken before, during and after the procedure in order to evaluate the effectiveness of the procedure to be performed, and I agreed.

• I understand that no guarantee is given as a result of the procedure to be performed on me.

• I did not encounter any coercive behavior in purchasing this application.

• In these conditions, MICROPIGMENTATION  I voluntarily agree to have it done and to pay the costs required for this application.

 

THE PERSON TO whom the APPLICATION IS MADE

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Name and surname:

History:

Signature:

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THE PERSON WHO MAKES THE APPLICATION

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Name and surname:

History:

Signature:

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THE PERSON WHO WITNESSED THE APPLICATION

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Name and surname:

History:

Signature:

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