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Informed Consent (PMU) Salon Esprit

Informed Consent (PMU) Salon Esprit


Algemene Vragen

Naam + voorletters
Geslacht M / V
Naam wettelijke vertegenwoordiger
Straat en huisnummer
Postcode en  woonplaats 
E-mailadres
Geboortedatum en plaats
Beroep
BSN nummer
Telefoonnummer / mobiel

 

Bent u lichamelijk gezond?  Wel/Niet
Ik heb een allergie (metalen / nitril)    Wel/Niet
Ik gebruik contactlenzen – alleen bij eyeliner  Wel/Niet
Ik heb herpes simplex virus  Wel/Niet
Ik ben momenteel zwanger / geef borstvoeding  Wel/Niet
Ik heb ooit last gehad van hemofilie  Wel/Niet
Ik heb last van een immuunstoornis | HIV | aids  Wel/Niet
Ik heb ooit last gehad van een chronische huidaandoening  Wel/Niet
Ik gebruik op dit moment anti-stollingsmiddelen / bloedverdunners  Wel/Niet
Ik heb ooit last gehad van hart / vaatziektes  Wel/Niet
Ik heb ooit last gehad van een spuitje van de tandarts (Lidocaïne)  Wel/Niet
Ik heb ooit last gehad van diabetes  Wel/Niet
Ik ben onder behandeling van een huisarts / medisch specialist  Wel/Niet
Ik gebruik medicijnen, zo ja  
Ik heb de afgelopen 24h het volgende gebruikt: aspirine / vit. E / groene thee / alcohol  Wel/Niet

 

Ondergetekende verklaart hierbij het volgende


De keuze om permanente make-up te laten aanbrengen heb ik weloverwogen en uit vrije wil gedaan.

  • Voor en tijdens de behandeling was ik niet onder invloed van alcohol of drugs. 
  • Ik ben geïnformeerd over de risico’s die kunnen ontstaan als gevolg van het aanbrengen van de permanente make-up, zoals infecties, littekenvorming en allergische reacties. 
  • Ik heb op dit moment geen verkleuringen, zwellingen, bulten of enige andere vorm van irritatie op mijn lichaam en beschouw mezelf gezond genoeg om deze permanente make-up te laten aanbrengen.

** Dit formulier kan bij een inspectie door de toezichthouder van de GGD worden ingezien.