PMU Consent form

BROWHAUS LLC

Permanent Cosmetics form
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact name
Emergency contact phone

Area CodePhone Number
How did you hear about us? (optional)
Please choose your desired service(s)

Brow tattoo/ correctionFreckle/ beauty mark tattooEyeliner tattooLip blush tattoo
Do you have any previous tattoo in the area?*

YesNo
Are you pregnant or nursing?*

YesNo
Have you taken Accutane within the last year?*

YesNo
Have you had Botox injections in the last 2 weeks?*

YesNo
Have you received laser treatment or a chemical peel on your face in the last 4 weeks?*

YesNo
Medical info
Please select all that apply.

Currently on medicationCurrently under medical care for a conditionKeloid scarringPsoriasis or eczema in areaTrichotillomaniaBleeding disordersEpilepsyHeart conditionsHormone therapyHepatitisHIVTaking blood thinnersAllergies to anesthetics (numbing)Nerve damage in the areaBruise, swell or bleed easilyDiabeticCancer or ChemotherapyAutoimmune disorderGlaucomaHerpes or cold sores
Please disclose any current medications as well as those taken in the last 6 months.
Please specify any health conditions including allergies.
I have disclosed any and all allergies, medical conditions, and medications I am taking.*

Yes, I have.No, I have not.
Lifestyle
Please select all that apply.

Tans or uses tanning bedsSpends a lot of time in the sunSpends a lot of time in chlorinated poolsReceives botox or fillersSmokesDrinks alcoholTints eyebrowsUses retin-A or other chemical exfoliantsOily skinCombination skinDry skin
Informed consent

Please read thoroughly.
May we use your photos for social media, educating and advertising purposes?

YesNo
I understand that obtaining permanent makeup is my choice alone. Permanent makeup will result in a permanent change to my appearance. I understand and accept that such procedure is a process, often requiring a follow-up to achieve best results, and that 100% success can not be guaranteed.
I understand that I will have permanent makeup applied using single-use, sterile, disposable instruments. I understand that that the permanent makeup site may take 2 weeks or longer to heal.
I acknowledge that infection is always possible as a result of any procedure in which skin is broken. I agree to follow all suggested instructions concerning the care of my permanent makeup while it is healing.
I understand that this procedure is permanent in nature, but will fade over time. Fading can alter original color, which will help determine when it is time for a touch-up.
I understand that the actual color of the pigment may be modified after the procedure, due to the tone and color of my skin. I understand that it is my responsibility to follow aftercare instructions for the best possible results and that my healed result is entirely impacted by the way I care for my new permanent makeup.
I understand receiving this service is my choice alone and is not a medical necessity. I agree to hold harmless BrowHaus LLC, my artist, and Criselda Cox for any undesired results that may come from recieving permanent makeup services.
I have read and acknowledged this page.*

Yes
Signature
Date*

MonthDayYear
Date
Should be Empty:

BROWHAUS LLC

Medical info

Lifestyle

Informed consent