PMU CLIENT FORM
CLIENT ACKNOWLEDGMENT AND CONSENT FOR PROCEDURES PERFORMED BY TRANSFORM BEAUTE LLC: Client acknowledges and states that they are freely and voluntarily consenting to undergo Microblading/Ombre/Eyeliner/Lips Blush (permanent make-up/cosmetic tattooing procedures) as performed by Transform Beaute LLC. The client understands that the likelihood of injury or allergic reaction is influenced by numerous factors, including but not limited to, the client’s natural skin pigmentation, skin texture and quality, and failure to adhere to post-treatment care guidelines. Consequently, Transform Beaute LLC reserve the right to refuse to perform the procedure on individuals they determine maybe at greater risk of injury or poor results due to the client’s unique skin characteristics and/or the basis of answers to the Health Questionnaire. In order to ensure the best results to your procedure and that the treatment is performed in a safe manner, the client acknowledges that they have answered the following questions truthfully and completely. Any information reported in the Health Questionnaire is confidential, shall be treated as such, and will be used only for the purposes of evaluating factors that may increase the likelihood of injury or allergic reaction to the client. Transform Beaute LLC cannot be held liable for any injury or allergic reaction that results from the client’s failure to provide truthful and complete answers to the following health questions.
Appointment Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
How did you hear about us?
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Family/Friend
Google
Facebook
Instagram
Other
If someone referred you, please state their name:
Please indicate if you suffer from the following diseases or are prescribed or otherwise taking any of the named medications:
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Hemophilia
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV positive
Skin diseases (Eczema, rosacea, psoriasis, acne, ichthyosis, vitiligo, hives, seborrheic dermatitis, alopecia aerata)
Allergies
Autoimmune diseases
Epilepsy
Cardiovascular problems
Use of medications such as anticoagulants that thin the blood
None of the above
Other
Consent for Microblading Procedure: Please read and check.
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I am currently not under the influence of any drugs or alcohol.
I am not pregnant.
I am not breastfeeding.
I do not have a pacemaker.
I do not currently nor have I taken Accutane within the last 12 months.
I have not had Botox and/or other cosmetic filler procedures within the past two weeks.
I have not had surgery of any kind within the past six months.
I have not taken any blood thinning medication with the past 72 hours nor have I taken aspirin within the past 24 hours.
I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.
I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas because they will alter the color.
I understand that sun, tanning beds, pools, some skin care products and medications can affect my semi-permanent makeup.
I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done today.
I understand that implanted pigment color can change or fade over time due to circumstances beyond the salon’s control and I will need to maintain the color with future applications and a touch‐up session within 6‐8 weeks.
I acknowledge that the microblading/eyeliner/lips procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper‐pigmentation.
Aftercare instructions will be explained to me and are attached to this consent form. With that said, I will follow to the best of my ability. If I have questions I will text or email my PMU artist.
I acknowledge that I am at least 18 years of age and I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Transform Beaute, LLC to perform microblading and other semi-permanent makeup procedures on me. I hereby release Transform Beaute, LLC from any liability arising from the risks that are known and/or inherent in the procedures. I understand that there will be a no refund policy as material cost and time cannot be reimbursed.
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I agree
Optional Photography Release Consent:
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I hereby grant Transform Beaute, LLC the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary. I further expressly assign any copyright in these photographs for any advertising or other purposes, along with any comments I may provide.
No, Please don't use my pictures
Signature
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