Consent Form

Please read through our Consent Form carefully and please Call us if you have any questions!

SMP Revival

Consent Form

To the Client:

You have the right to be informed about your treatment so that you may make a decision to undergo the procedure, knowing the risks and hazards involved.


I   __________________________ have received a consultation either online or in person with and Revival SMP Studio consultant and I consent to having a __________________________ treatment carried out upon myself.


I have read, understood, been truthful in my answers to the best of my ability and have completed the questionnaire concerning my medical history and current condition and have supplied a signed document of this to Revival SMP Studio. I am therefore aware of the consequences of any negative result occuring due to omitting any personal medical information.


I understand that I require a second and third etc follow-up treatment on the original treated area, following the initial procedure. These follow up procedures are included in your treatment quote. I thereby understand and have agreed to the cost associated with my quote and treatment. Additional sessions may also be required to achieve the best outcome – Any additional sessions needed outside of the quotation due to the client’s failure to follow aftercare will be at the client’s cost and will be charged per session.


Further treatments such as facial micropigmentation, scar camouflage etc outside the scope of the initial quotation are based on an initial assessment whereby a separate cost will be provided.


A SCALP MICROPIGMENTATION treatment means you are injected with a small needle into the epidermal/dermal layer, with the aim of placing pigment into the skin, therefore camouflaging the appearance of hair loss. The process is generally performed over two sessions, and sometimes an additional session may be required. Full settling of the pigment normally takes place over a 7-10 day period but in some cases can take in excess of 6 weeks due to skin anomalies.


I have been informed about the treatment, procedure, indications, expected results and possible side effects, in terms of how everybody’s skin/body reacts differently to this and thus affecting colour and results.


I understand that I may experience discomfort during treatment. I understand there may be redness and/or tenderness for several days after my treatment, however these symptoms will resolve.


Every client’s skin is completely unique. Although the results are usually positive enhancement, I have been informed that the practice of this treatment is not an exact science and that no guarantee can be or have been made concerning the expected results in my case now and at any time during the future, and understand the treatment is non refundable.


I acknowledge that when there are bald areas of the scalp, my hair must be worn at the appropriate zero length to ensure an even transition and match between my natural hair and the SMP treatment. This applies for the application of the treatment as well. I have been advised if this applies to me.


I am undergoing treatment of my own free will. I agree that this procedure is being performed for cosmetic reasons and I understand that whilst every precaution will be taken to prevent complications and that whilst complications from this procedure are rare, they can and sometimes do occur.


I accept full responsibility for any complications or negative results that may occur and therefore absolve Revival SMP Studio and any associated person/practitioner of any blame resulting there from. I understand that failure to follow the aftercare instructions may result in uneven healing and an unsatisfactory result. Revival SMP Studio reserves the right to use all client photos and video content and images for marketing purposes. I also agree that I will not discuss, post comments on social media or the internet or release any photographs of my procedure or results thereafter unless specifically agreed between all parties, and I am liable for any damages and the associated legal costs this confidential disclosure may cause. I agree that this procedure will remain confidential until Revival SMP Studio deem it appropriate to market such information, with my consent below.




I understand that levels of discomfort vary by individual. Skin numbing cream featuring lidocaine may be used for temporary relief during your treatment, by your request only.


I accept full responsibility for any reactions or negative treatment results potentially caused by the use of any numbing agents   YES ____




I have been offered a test patch prior to starting treatment and release Revival SMP Studio and/or their representatives from any liability related to any reactions, negative results or allergies that may take place now or in the future.


YES _____




I agree that this constitutes full disclosure, and that it supersedes any verbal or written disclosures. I certify that I have read, and fully understand the above information and that I have had sufficient opportunity for discussion and to have any questions answered.



Client Signature _______________________________                         Date _________

Consultant Signature ___________________________                         Date _________


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