PERMANENT MAKEUP PROCEDURE Consultation Form

Full Name*

First NameLast Name

Phone Number *

Please enter a valid phone number.

Email

example@example.com

Date of Birth *

Date

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Please select which treatment you are having (you can select more than one option if need be):*

EyebrowsEyelinerLip Blush

If you have had any of the below recently please state yes and give additional information requested where relevant. Otherwise, enter N/A or No.

Do you have any Allergies or Sensitivities, including dietary, (an allergy to preparations used for local anaesthesia)? (List here)*

Are you currently on any medication, topical or oral, antibiotics, steroids, especially blood thinners? (List here, along with the conditions they are treating)*

Have you had/used any recent Exfoliating Treatments (if yes please indicate date) Have you had any recent Facial Waxing (if yes please indicate date)*

Have you used any recent Resurfacing Products, wit. A, Retinol? (if yes please indicate date) *

Have you taken any detoxifying or anti-inflammatory herbs (such as milk thistle, turmeric, etc.) in the past 2–4 weeks?*

Have you had any recent Botox or Fillers (if yes please indicate date)*

Have you had any recent Sun Exposure, Sunbeds (if yes please indicate date) *

Have you had any recent Surgery (if yes if yes please indicate date) *

Do you have an Autoimmune Diseases? (Please identify)*

Are you in the middle of any dental procedures or treatment at the moment?*

Are you pregnant or breastfeeding?*

Do you have, or you had, any of the following: (PLEASE READ CAREFULLY & THOROUGHLY)

	YES	NO
Chemotherapy or Raiotherapy
Cancer
Anaemia
Eczema in the treatment area
Active Psoriasis in the treatment area
Systemic Syndrosis (SCLERODERMA)
Sjögren’s Syndrom
Systemic Lupus Erythematosus (SLE)
Diabetes
Autoimmune Vasculitis (e.g. dermatomysitis)
Pemphigus
Haemophilia
Epilepsy
HIV
Hepatitis
Thyroid Condition
Heart Problems, Pacemaker
Rheumatoid Arthritis
Crohn’s Disease/Ulcerative Colitis
Vitiligo
Multiple Sclerosis (MS)
Liver Disease
Eye disease / eyes surgery
Skin Condition
Melasma
Keloid (raised) Scars
Prone to Scarring, Poor healing of wounds
Herpes
Isotretinoin within the last 6-12 months

Other Medical Conditions?

Any other information you would like to provide?

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Agreement Terms

I understand that during subsequent visits it is my responsibility to inform the technician of any updates to the answers I have provided on this form.I certify that the information above is true & correct and I have not withheld any information requested on this form. I understand that it is my responsibility to inform the technician of any medical or health conditions, as they may affect my treatment. Failure to answer truthfully may result in personal injury. My submission of this form constitutes my consent to treatment. I hereby give my consent and authorisation voluntarily. I release this establishment and its agents from liability for any injury, loss or damage that may result from any information I have withheld.I understand that even though the highest quality numbing agents and pigments are used during my PMU Procedure with WM Permanent Make Up, there is a risk of an allergic reaction to one or more of the ingredients of the products used during my procedure. I understand that even with a negative Patch Test result, an allergic reaction can still occur that can not be predicted, and I understand that WM Permanent Make Up can not be held liable for an allergic reaction.I understand that my Permanent Makeup Artist CAN NOT provide medical advice in the event that I do have an allergic or otherwise adverse reaction to my procedure, and I certify that I will seek qualified medical attention in the event that I experience symptoms of an allergic reaction or potential infection.I agree to follow the Before & After Care Instructions provided perfectly in order to ensure my satisfaction with the final results and only use the after care products provided.I understand that if I have an MRI or CAT scan, I must tell the radiologist that I have cosmetic tattooing. I might experience a slight tingling in the affected area.I understand that my technician will be taking photographs before and after the treatment for record keeping and liability purposes and that this is necessary if I am to undergo the procedure. These photos may be shared on WM Permanent Make Up social media accounts and if I wish to remain anonymous I have the right to request my identity be hidden (close-up of brows, lip & eyes only.)I understand the effect of the treatment depends on many factors, including biochemistry, skin type and colour, therefore it is not possible to guarantee the expected effect or that they will be identical for each client, the number of treatments and their effect is determined individually for each person. The after the first treatment, small flakes with a loss of some pigment may occur and colour intensity may change. Treatments require a perfecting Touch-Up (one or two) to achieve optimal results. In the first days the area of the treatment is up to 40% to 60% darker and 10-15% thicker than the healed results. This will subside and look more natural once fully healed. The final result cannot be determined until area of the treatment are completely healed, around 4-12 weeks.My decision to undergo permanent makeup procedures is informed and deliberate.

PERMANENT MAKEUP MEDICAL INFORMATION:

MEDICAL CONTRAINDICATIONS – AUTOIMMUNE CONDITIO
Autoimmune diseases may be a contraindication for permanent make-up, as they can affect the immune system, skin healing, and how the body reacts to pigment. Below are the most common absolute and relative contraindications:

Absolute contraindications (treatment is not recommended):

Systemic Lupus Erythematosus (SLE)– high risk of skin complications and poor wound healing.
Systemic Scleroderma– skin is very tight, making it difficult to implant pigment evenly.
Active Psoriasis in the treatment area – risk of the Koebner phenomenon (new lesions triggered by skin trauma).
Pemphigus – extremely sensitive and fragile skin.
Type 1 Diabetes (autoimmune origin) – increased risk of infection and delayed healing.
Sjögren’s Syndrome – dry skin and mucous membranes, which may affect the healing process.
Autoimmune vasculitis (e.g. dermatomyositis) – weakened skin and disrupted healing.

Relative contraindications (require approval from your physician):

Hashimoto’s Thyroiditis – autoimmune thyroid inflammation.
Rheumatoid Arthritis – disease should be stable; increased risk of infection and healing issues.
Crohn’s Disease / Ulcerative Colitis – risks related to immunosuppressive treatments.
Type 2 Diabetes (with autoimmune component) – treatment is possible only with well-controlled blood sugar levels.
Vitiligo – risk of spreading depigmentation in the treated area.
Multiple Sclerosis (MS) – treatment only during remission and when the condition is stable.
Celiac Disease – minimal risk if on a strict gluten-free diet and the condition is well-managed.

Why are autoimmune diseases a concern for PMU?

Delayed healing – many autoimmune diseases affect the skin’s ability to heal.
Increased infection risk – especially if the client is taking immunosuppressants.
Unpredictable pigment retention – the immune system may reject or react to pigment.
Flare-ups – skin trauma can trigger worsening of the disease.

Always consult with your doctor before scheduling a treatment.

PMU may be considered if the disease is in remission and your doctor gives clearance.

Treatments should be avoided during active flare-ups.

Highest hygiene standards must be followed to reduce infection risk.

PERMANENT MAKEUP INFORMATION:

Permanent Makeup is a form of cosmetic tattoo. We are implanting ink below the surface of the skin with a manual tool or machine. There may be risks associated with this procedure.
The treatment is semi - permanent and may fade over time. It is necessary to have the colour refreshed, usually once a year, max in two years (Longer for Machine Procedures depending on skin type and adherence to aftercare instructions).
Those with oily skin may need to return sooner for refreshing (between 9-10 months for Hair Strokes.) For this reason our Machine Brow (Powder Brows) techniques are preferred for oily skin. It will last longer and age better than Hair Strokes for this skin type.
Although a topical anaesthetic is used during the procedure, and every effort will be made to ensure my comfort, sensitivity or discomfort may still be felt. Skin may be red and /or swollen after the procedure.
Please do not drink alcohol 48 hours prior to the treatment, or caffeine the day of the treatment. Please refrain from exercise the day of the treatment. All of these can increase blood flow in the body and this can cause excessive bleeding. If there is excess bleeding during treatment we may not be able to finish the procedure. Unless medically necessary, please avoid taking things that thin the blood like fish oils, herbals, Vitamin E, aspirin, ibuprofen.
Please do not shape or wax your brows for at least 4 weeks prior to the procedure.
AHA products and retinoids should be avoided for 4 weeks prior to the procedure in eye area only (resurfacing or anti-anting products generally contain these ingredients.)
Botox and Fillers may not be used within 4 weeks before/after treatment either.
Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure .
Chemical and laser peels should be avoided no less than 6 weeks prior to procedure .
Hormone therapies can affect pigmentation and/or cause sensitivity
Discontinue use of any brow/lash growth serums like Latisse 6 month prior to permanent makeup procedures, as it can cause sensitivity and affect pigment
The following medical conditions require a note from your doctor giving consent: Diabetes, Auto - Immune disease, and any other medical condition that causes slow healing or a high risk of infection. It is possible that certain medications and pre - existing health conditions may interfere with the healing process or put you at increased risk of complications, this is why a consultation with a health professional before receiving a body art service is necessary.
Permanent Makeup procedures require 2 to 3 sessions. For best results, clients will be required to return for a re-touch appointment. This will take place 6-12 weeks after the initial procedure, and is Not included in the cost.
Please be aware that colour intensity will be significantly darker and sharper immediately after, and for a few days after the initial procedure, but the colour will reduce by about 40% upon healing.
The Permanent Makeup Procedure area will vary greatly in shape and colour intensity throughout the healing process. This is entirely normal! It takes about 8 weeks before the skin has finished healing and we can accurately assess the healed result for shape/colour/intensity. We can NOT go back into skin until the 4-8 weeks healing phase has passed, and though the healing phase can be stressful, please trust the process... we will address any shape/colour challenges you may have during the 8-12 week perfecting touchup session.

PERMANENT MAKEUP - DISCLOSURE & CONSENT FORM

I understand this is a semi-permanent makeup procedure that may fade over time or not. It will require follow-ups and touch ups to maintain desired results. The pigment lasts depends on many factors, including my skin type, age & lifestyle, as well as hormones, health & medications. I understand that with oily skin types, hair strokes can heal less crisp, or may result in a powder effect. For this reason the Powder Brow (machine shading) is the preferred technique for oily skin. It will last longer and age better than Hari Stroke for this skin type. Some skin types may require a 3rd touch up to achieve desired results.
My post-treatment care at home will determine in great part the successful outcome. For this reason there is no warranty or guarantee made to me as a result of this procedure and the final result cannot be guaranteed. There are no refunds for this procedure, as results will vary and individual results are not guaranteed. I accept the responsibility for determining the shape and position of the brows, lips, eyeliner as agreed during the consultation and pre-draw.
I understand the permanent skin pigmentation procedure carries with it a risk of known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent colour, and spreading, fanning or fading of pigments. There may be discomfort and pain during this procedure. There is a possibility of bleeding during treatment. During and after the treatment temporary swelling, redness and/or itching may occur. During the treatment, despite technician’s expertise and all the precautionary measures, injury is possible. Despite the application of the most advanced and the top quality pigments, allergic reaction is rare but possible. Allergic reaction to the anaesthetic is possible. I agree to seek medical attention if complications are suspected or developed.
Though semi-permanent, the pigment may last permanently and may not fade. The laser or acid removal procedures may be required to remove pigment from skin. I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my shape and pigment. I acknowledge some of these potential adverse changes may not be correctable.
I understand my technician is obligated to, and will, perform treatment in strict compliance with all hygiene and health protection measures as regulated by Health UK. The highest standards of hygiene are met and sterile, disposable needles and pigment containers are used for each individual client, procedure and visit.

FEES & POLICIES

The consultation or online consultation (through messaging, email, or WhatsApp) is offered prior to having the service. This consists of your answering relevant health-related questions to ensure it is safe for you to have the treatment done.

A deposit of Service Cost Booking Fee is required to schedule your treatment, but will be subtracted from the cost of your treatment.

If you cancel the appointment with more than 72 hours notice, your deposit will be refunded.

With less than 72 hours notice, the Booking Fee is non-refundable for cancellations, and can only be rescheduled (up to 48 hours prior).

I do understand that schedules sometimes change- if this is the case and you need to reschedule your appointment, you may do so and transfer your deposit as long as it is with a minimum of 72 hours notice. Rescheduling within less than 48 hours will result in forfeiting the booking deposit, and require a new Booking Fee of the full service price to reschedule.

**Exception clause in place under the COVID-19 Policies. The pre-screening call will allow for cancellation/rescheduling due to Covid symptoms at/before the 72 hours window, and an emergency exception for NEWLY onset COVID symptoms the day of your procedure allows you the ability to reschedule if you will provide information form your doctor.**

If you fail to notify to me not coming for yours appointment, or you arrive more than 15 minutes late for your service, you will forfeit your booking deposit, and be required to pay the service in full prior to re-booking to respect the high demand of booking requests, we want to ensure we are reserving our sought after booking slots for clients that are 110% committed to attending their appointment.

Chronic Rescheduling challenges will result in no longer being able to book future sessions. Clients may reschedule twice within the policy guidelines above before they forfeit their booking deposit.

By signing and submit this form, I am acknowledging that I have read and fully understand the policies.

I fully understand the procedure and give permission to my technician to perform the Permanent Makeup procedure I've chosen, and all of the associated procedures and steps involved. By submitting this form, I am acknowledging that I have read and fully understand the policies.*

YesNo

I consent to Wioletta Malochleb Permanent Makeup using this information to contact me.*

YesNo

I consent to photograph, filming, recording and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose, any promotional materials and for Social Media.*

YesNo

I confirm that I HAVE NOT had any of the following symptoms in the last 10 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat | I DID NOT test positive in the last 10 days

YesNo

Signature*

Date*

Date