PMU Pre-Screening

PMU Pre-Screening

To be able to book for any Permanent Makeup procedure with out an in person consultation, please fill out our forms and allow 2-4 business days for a reply.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Date of birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What Permanent Makeup procedure are you looking for? *
If you selected eyebrows, which procedure?
How did you hear from us?
Are you pregnant or breastfeeding? *

Yes No
Do you have a previous tattoos in the area you are inquiring about? (eyebrow or eyeliner) *

Yes No
If your answer is yes, please send us a clear photo of your work.
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Do you have any problems healing? *

Yes No
Does your skin keloid? *

Yes No
Have you ever used accutane? *

Yes No
if yes, when was the last time you used it?
Do you tan? *

Yes No
Do you experience prolonged bleeding? *

Yes No
Do you have high or low blood pressure? *

Yes No
Do you suffer from dizziness or fainting? *

Yes No
Have you ever had cancer? *

Yes No
If yes, how long have you been on remission?
Have you ever been required to take antibiotics before undergoing a medical procedure? *

Yes No
Do you have any allergies? *

Yes No
If yes, what are you allergic to?
Do you have oily skin? *

Yes No
Do you easily scar from minor injuries? *

Yes No
Do you have any autoimmune deceases? *

Yes No
If yes, what kind?
Do you have hepatitis? *

Yes No
Do you have any heart conditions? *

Yes No
Do you have diabetes? *

Yes No
Are you anemic? *

Yes No
Have you experienced hypo/hyper pigmentation? *

Yes No
Do you use Retin-A, Glycolic Acid, or other exfoliating products regularly? *

Yes No
Do you have any cosmetic fillers or botox? *

Yes No
Are you on any medication? *

Yes No
If yes, please list bellow.
I have made an informed decision, and consent to undergo this Permanent Cosmetic procedure. *

Agree Disagree
I understand that the shape/color for my procedure will be determined during the consultation, and that the technician will not begin the procedure until she and I are both satisfied with the shape. *

Agree Disagree
I understand that my technician will chose pigments based on the desired healed results, but I will ultimately approve of the choice made. *

Agree Disagree
I understand that there is no way to predict with 100% accuracy how the pigment will appear once fully healed, as skin texture, tone, etc. play a large role in the overall appearance of the healed results. *

Agree Disagree
I understand that no guarantees can be made as to the final results, as my technician cannot control how my skin heals. *

Agree Disagree
I understand that Permanent Makeup is a form of art and that while the purpose of this procedure is to enhance my natural beauty, perfection is not guaranteed. *

Agree Disagree
I agree to (Choose One): RECEIVE/WAVE a spot test prior to application and I agree to release Lusila Sandoval, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. *

Receive Wave
If you would like to receive a patch test, you would have to book a separarte appointment to be able to perform one at a $75 additional fee. Once healed you will be required to bring a doctors note stating you are not allergic.
Please upload a clear picture of your eyebrows/eyeliner in clear daylight.
*

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Please upload a clear photo of how you wear your makeup on your eyebrows/eyeliner in clear daylight.
*

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Please upload a picture of what you’re looking to get done. Please visit my Instagram (browsbylucy)or website (browsbylucy.com) for reference.
*

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I understand that a booking fee is required in order to book and my booking fee is non-refundable/non-transferable. Also that no refunds are issued after the procedure is completed for any reason whatsoever. *

Agree Disagree
This document is to advise you of our company’s Cancellation & 48 hour Rescheduling Policy. All booking fees are non-refundable/non-transferable. Due to the overwhelming demand for our services and limited appointment slots, it is critical that you provide us with at least 48 hours’ prior notice if you wish to reschedule your scheduled appointment. Having such advanced notice allows us to fill the applicable appointment slot from others requesting an appointment. If you need to reschedule your appointments with us for any reasons (including events beyond your control), you must notify us as soon as possible via text only and in any event at least 48 hours prior to your scheduled appointment time. If you reschedule an appointment less than 48 hours before your scheduled appointment appointment time, you will forfeit your Booking Fee and will be asked to leave another booking fee of $100 in order to reschedule your future appointment time. If you fail to show up for your appointment time and fail by calling us prior to your scheduled appointment time, you will be asked to pay appointment in full in order to schedule any future appointment times. *

Agree Disagree
Signature

Clear
Date

Month Day Year
Date Hour Minutes AM/PM Option
Thank you! We will contact you soon if we need any more info or if we feel the need for an in person consultation.

Please make sure to visit our website and read thePre-Care portion.
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