SMP CONSENT FORM

Client Information

Name:

Address:

City:

State:

Zip:

Telephone:

Can we leave a message on this line?
YesNo

Email:

Emergency Contact Information

Name:

Telephone:

Relation:

Identification Verification (Must be 18yrs of age to receive SMP services):

Photo ID, Driver's License, Passport, Birth Certificate

Procedure Details

You are receiving Scalp Micropigmentation (SMP) treatment today. SMP is a personalized, specialized and non-invasive procedure that uses micro-needles to deposit natural pigments into the scalp. The result creates the appearance of tiny hair follicles, enhancing your look and providing the appearance of fuller hair, natural-looking hairlines, density to thinning areas, and concealing scars or other hair loss concerns.

Please specify the area on your scalp where the SMP treatment will be performed:

Client's Signature:

Date:

*By selecting checkmark, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement.

By check marking this consent form, you acknowledge your understanding of the SMP treatment and agree to follow post-procedure care instructions.

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