PMU CONSENT FORM
Name
*
First Name
Last Name
Date of Birth
*
Occupation
*
E-mail Address
*
Mobile Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
What are you trying to achieve?
EMERGENCY CONTACT
First Name
Last Name
EMERGENCY CONTACT NUMBER
-
Area Code
Phone Number
Eyebrow Photos
Please take a close up photo of each of the views requested below and upload them in the appropriate file upload
Close up front view of both brows
*
Upload a File
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of
MEDICAL INFORMATION
What is your skin type?
DRY
COMBINATION
OILY
Do you have any blood borne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis (A,B,C,D) ?
YES
NO
Are you currently pregnant or breastfeeding? If yes, you must not be pregnant or nursing at the time of appointment.
YES
NO
Have you ever had an allergic reaction to any of the following?
ANAESTHETHICS
ADRENALINE
LATEX RUBBER
VASELINE
METALS
LANOLIN
MEDICATIONS
GLYCERINE
LIDOCAINE
Please include of any other allergies, 'N/A' if none:
CHECK ALL THAT APPLY:
HIV/AIDS
Heart condition
Herpes
Cancer
Active chemotherapy
Currently taking accutane
Keloid scars
Hepatitis
Hemophilia
High blood pressure
Diabetes
Other tattoos
Bruise / Bleed easily
Eczema (face)
Autoimmune conditions
NONE OF THE ABOVE
Special requests, concerns or remarks:
General Consent & Procedure Permit
Please read these statements carefully - Permanent cosmetics are a form of tattooing. - Retouch procedures may be required. - A healing period of 4 to 6 weeks is required before any touch-up procedure can be performed. - On rare occasions the pigment may migrate under the skin. - Application of permanent cosmetics can be uncomfortable. - The pigments will fade. - Immediately after the procedure, the pigment can be 30% to 50% darker than the desired result. - There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare. - A negative allergy test result will not guarantee that you will not have an allergic reaction. - Infections can occur if aftercare is not followed. - Allergic reactions to anaesthetics can occur. - There may be swelling and redness following the procedure. - You may experience minor bleeding. - If you have a MRI scan within 3 months your permanent cosmetics procedure we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.
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I have read and understand the above statement
1. I hereby authorize Julie Le (PMU technician) 2. Of [CAMBEAUTYHAUS] to perform the microblading/ombre brow treatment upon myself. If any unforeseen condition arises in the course of this procedure(s), calling in their judgement in addition to, or different from those now contemplated, I further request and authorise the technician to do whatever they deems advisable and necessary in the circumstances. 3. I accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. 4. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I confirm I have completed a patch test for this procedure, within 6 months of the treatment date. 5. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-3 years. 6. I have been informed that the highest standards of hygiene are met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit. 7. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results and that 100% success cannot be guaranteed. I understand this is why I need to return for a retouch procedure. 8. I understand that a retouch procedure will be performed 1-3 months after the initial procedure and after a 3-month period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties. 9. The result of the procedure is determined by the following: - Medication - Skin Characteristics - (dry, oily, sun-damaged and thickness) - Natural skin undertones - (blending with chosen pigment) - Personal pH balance of skin, which changes from visit to visit - Alcohol intake and smoking - Post procedure care treatment 10. Upon completion of the procedure there may be swelling and redness of the skin, which will subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately following the procedure, however, using cosmetics, excessive perspiration wetting and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. You can however, be assured the procedure, even after only one treatment, looks acceptable and you should feel comfortable appearing in public without additional makeup on the affected area. 11. I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary in colour according to skin tones, skin type, age and skin conditions. I understand that some skins except pigment more readily than others and no guarantee to an exact effect or colour can be given. 12. I am aware that the lip procedures may stimulate any dormant virus such as herpes (cold sores). I am informed that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment. 13. To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol, pregnant or breastfeeding. 14. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. 15. Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by
[enter technician's name]
(microblading technician) 16. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the microblading procedure(s)
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I have read and understand the above information
Topical Anaesthetic Form
Allergic Reaction– Allergic reaction can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptom associated with allergy. Numbness - We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is totally numb while others say they experience some discomfort. Procedure – For all procedures a cream or gel topical anaesthetic is used. These products are perfectly safe, and can be purchased over the counter from any chemist. The anaesthetic is placed over the treatment area for between twenty to thirty minutes then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between one and four days. You should always follow your post procedure instructions.
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I have read and understand the above information
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