Permanent Make up

1. Client Information

Name: __________________________
First Name: _______________________
Address: ______________________
Postal Code: _______ City: __________________
Phone: __________ Mobile: __________
Date of Birth: ____ / ____ / ______

Person or establishment who recommended you: __________________

Do you wish for all contact to remain confidential?
☐ Yes ☐ No

2. Service Information

Micropigmentation session date: __________________

Touch-up session #1 (recommended between 1 and 3 months after initial session): __________________

Next touch-up session (not mandatory, recommended minimum 1 month after previous touch-up, depending on micropigmentation evolution and practitioner/client advice): __________________

Additional sessions may be necessary depending on skin reaction and desired result.

These subsequent interventions constitute maintenance sessions, billed according to current rates.

Depending on degradation or evolution of pigmentation over time, the service may require a complete redo of the work. In this case, the “creation” rate may apply, given the working time and technical skill required to achieve an optimal result.

Regular maintenance is recommended: it is the client’s responsibility to request a new service as soon as pigment evolution requires it.

3. General Information Regarding Micropigmentation

Micropigmentation is an aesthetic technique consisting of introducing pigments into the superficial layers of the skin, involving skin breach.

The practitioner commits to implementing all professional skills, hygiene rules, and means necessary for the service.

The practitioner is held to an obligation of means, not results.

Micropigmentation is a semi-permanent technique whose evolution over time depends on many factors.

Photographs taken immediately after the service do not constitute the final result, which can only be appreciated after complete healing.

4. Touch-up Deadlines and Complaints

A touch-up session is generally necessary to stabilize and adjust the micropigmentation.

It must be performed within a recommended period of 1 to 3 months after the first session.

Any correction request must be made within this period.

Any claim made several months after the service cannot be considered a service defect, as micropigmentation is an evolving technique depending notably on:

• Biological factors: skin type, skin pH, metabolism, cell renewal, sebum secretion, healing…

• Environmental factors: sun, UV, heat, perspiration, water, humidity, water vapor (pool, hammam, sauna)…

• Behavioral factors: compliance with care, lifestyle, cosmetic products, aesthetic or medical treatments, medication intake, manipulation or rubbing of the area…

These factors can alter pigment fixation and retention.

As micropigmentation requires regular maintenance over time, any intervention performed beyond the recommended touch-up deadline may be considered a maintenance service or a new creation, billable according to rates in effect on the day of the intervention.

5. Risks and Side Effects

• Redness
• Swelling
• Light bleeding
• Bruising
• Scabs
• Herpes reactivation
• Pigment fading or loss
• Rare allergic reactions

6. Client Commitment – Post-Service Care

The client commits to strictly following these instructions:

• Do not wet the area or touch it with wet hands
• Do not rub (cotton, towel, etc.)
• Avoid all contact with hair
• Do not apply makeup
• Avoid sun, UV, pool, sauna, hammam
• Avoid excessive perspiration
• Do not scratch

Mandatory application of a specific cream for minimum 15 days according to manufacturer and practitioner recommendations.

Non-compliance with these instructions releases the practitioner from liability.

7. Photo Authorization

☐ I authorize the use of photographs for professional purposes
☐ I do not authorize use

8. Technical Information

Type of service: ☐ Creation ☐ Touch-up ☐ Correction ☐ Camouflage

Area treated: ☐ Eyebrows ☐ Eyeliner ☐ Lips ☐ Areolas

Colors used: __________________

Mixtures made: __________________

Needles used (batch number): __________________

Material expiration date: __________________

Remarks: __________________

9. Medical Questionnaire

Herpes: ☐ Yes ☐ No
Contagious disease: ☐ Yes ☐ No
Medical treatment: ☐ Yes ☐ No

Pregnancy/Breastfeeding: ☐ Yes ☐ No

Conditions: ☐ Diabetes ☐ Cardiac ☐ Autoimmune ☐ Thyroid

Hepatitis: ☐ A ☐ B ☐ C ☐ Other

Implants/injections: ☐ Botox ☐ Silicone ☐ Other

Allergies: ☐ Yes ☐ No

Difficult healing: ☐ Yes ☐ No

Planned intervention: ☐ No ☐ <3 months ☐ 3-6 months ☐ >6 months

Ocular condition: ☐ Yes ☐ No

Medical Declaration

Any false statement or omission engages the client’s liability and releases that of the practitioner.

In case of hospitalization, illness, medical treatment, or medication intake, a medical certificate may be required, issued by the attending physician, attesting to the absence of contraindications to micropigmentation.

In the absence of presentation of this certificate, the practitioner reserves the right to refuse or postpone the service.

10. Pricing

Service price: __________ €

11. Technique Limitations

Progressive fading or disappearance of pigment constitutes normal evolution and cannot be considered a service defect.

12. Result Evaluation

The final result can only be evaluated after complete healing.

13. Document Preparation

This document is prepared in duplicate:
☐ One copy given to the client
☐ One copy kept by the practitioner

14. Consent and Signature

I certify having received all necessary information regarding micropigmentation.
I acknowledge having obtained satisfactory answers to my questions.
I understand the risks, conditions, and limitations of the technique.

I give my free and informed consent.

Mandatory handwritten mention:
“Read and approved, good for consent”

Name: __________________
Signature: __________________
Date: ____ / ____ / ______