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Blackhead, whitehead, milia extraction

Let us do this part
Today's Date:
Wed Jul 16 2025 07:35
Practitioner:*
***IMPORTANT COVID IMFORMATION***

You MUST attend your appointment alone. No friends or family are permitted, including children.

Please come to your appointment on time and wait outside to be called in. If you are early you will not be able to wait inside.

Clean face coverings must be worn at all times - we can supply for a small cost if you forget. Please read all signage on arrival for your safety. If you experience any symptoms prior to your appointment please contact us to reschedule.

Please fill this form out to the best of your knowledge - it is here to keep you, and me safe at your appointment.
Please read and answer
Skin congestion extractions*
Blackheads
Whiteheads
Milia
Unsure
 
Are you currently pregnant?*
Yes No
 
Are you suffering from any of the following?*
Heart conditions Hemorrhaging Hepatitis B or C Eczema Impetigo Diabetes Fainting HIV Common allergies (pollen/dust) Common allergies (metals) Covid symptoms Other None
Y
N
Are you on any medications, including acne medicines*
Yes
No
Details:
 
Your procedure will be carried out with sterilised equipment - it is up to you to keep the area clean after you leave. Aftercare is simple - touch the area as little as possible. Picking can lead to scarring! Bathe with clean water and gentle cleanser. I will supply some aftercare balm for the area to help condition the skin as it recovers. Use this once a day or as necessary. You'll need to avoid sun exposure before and after treatment.

Some common after effects can include - scarring, slight reddening, mild bruising or blistering. Infections are rare but can happen, if you feel you need to you can see your GP. Compliance with the aftercare guidelines is crucial for healing, prevention of scarring and hyper-pigmentation.

Boring but important!!!
I declare that I have read the above information and fully understand it. I understand that it is my responsibility to look after my skin after the treatment. I also understand that there are no guarantees and that I am releasing Holey Moley Piercing from all liabilities. My questions regarding the procedure have been answered satisfactorily. I hereby release Hayley Holey and Violets Beauty Bar from all liabilities associated with the above indicated procedure.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Address:
Postcode:
Date of birth:*
If you are under 16 your parent/guardian will be required
Gender:
Phone #:*
Email:*
Signature:*