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Consent Form (Scalp Micropigmentation)
Studio: [Studio Name]
Artist: [Artist Name]
Client: [Client Name]
Appointment: [Appointment Date] at [Appointment Time]
Client Information
•Phone: [Client Phone]
•Email: [Client Email]
•Date of Birth: [Client Dob]
Treatment Details
•Treatment Goal:
Shaved-head look with a defined hairline
Added density behind longer hair
Scar camouflage
Other: [Treatment Area Other]
•Pigment Shade: [Pigment Colors]
•Number of Sessions Planned: [Sessions Planned]
I approve the hairline design drawn on my scalp. I looked at it from the front and sides, and I'm happy with its shape and height.
My artist explained the hairline they recommend and why. I understand a hairline should still look natural as I get older.
Expectations
I understand SMP is a cosmetic tattoo that creates the look of hair follicles or added density. It does not grow hair, stop hair loss, or treat any medical condition.
I understand SMP takes more than one session to build up density, with time between sessions to heal. Each session is billed according to studio policy.
I understand the dots may look darker or bigger right after each session, and my scalp may be red. This settles as it heals.
I understand SMP fades over the years and may soften or shift in tone. Touch-ups will be needed to keep it looking fresh.
I understand that if my hair loss continues, the natural hair around the treated area may thin. The result may look different over time, and I may need more sessions.
I understand that to keep a shaved-head look, I'll need to keep my hair cut short.
I understand sun exposure fades pigment faster. Once healed, I'll protect my scalp with a hat or sunscreen.
I understand SMP is hard to remove. Removal may need laser treatment or another procedure, and full removal isn't guaranteed.
I agree to follow the aftercare instructions, including the rules on washing, sweating, and swimming while my scalp heals.
Risk Acknowledgement
I understand risks include infection, allergic reaction, scarring, dots spreading or blurring, uneven color, and being unhappy with the hairline.
I have been told that cosmetic pigments may affect MRI images. I will tell medical staff about my SMP before an MRI.
I understand that no specific result can be guaranteed.
** I consent to before and after photos for the artist's portfolio and marketing. I can say no without it affecting my treatment.
Medical Screening
What is causing your hair loss, if you know?:
•Has a doctor diagnosed you with a scalp condition (psoriasis, eczema, dermatitis, folliculitis, alopecia)?
Yes, describe: [Skin Condition Details]
No
•Rash, acne, sunburn, or open wounds on your scalp right now?
Yes
No
We'll wait until your scalp has healed before starting.
•Hair transplant or scalp surgery?
Yes. Date: [Recent Procedure Date]
No
Ask your surgeon when it's safe to have SMP.
•Using hair loss medications or topical treatments?
Yes, list: [Medication Details]
No
Don't stop or change any medication without talking to your doctor.
•Blood-thinning medications or bleeding disorder?
Yes
No
•Keloid or raised scarring history?
Yes
No
•Known allergies (latex, pigments, topical numbing creams)?
Yes, describe: [Allergy Details]
No
•Autoimmune conditions, diabetes, or immunosuppressant medications?
Yes
No
Other relevant medical information::
I certify that I have answered these questions truthfully and to the best of my knowledge.
My decision to get SMP is my own, and I consent to the procedure described above.
Client Signature: ______ Date: ______
Artist/Staff Signature: ______ Date: ______