Adored Ink PMU Consent Form

ADORED PMU

Permanent Makeup Service
Name*

First NameLast Name
Please provide a photo of your Driver’s License to ensure that you are 18+*

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Pre-Care Instructions

Please make sure to follow these pre-care instructions fully and completely. Failure to do so will result in cancelling your appointment and losing your deposit. If you wish to make a new appointment, a new deposit will be required.
- Do not drink coffee or alcohol 24 hours prior to your appointment.

- Do not take blood thinning medications/supplements (e.g. Aspirin, Ibuprofen, Vitamin E, Niacin, etc.) 24 hours prior.

- Retinoids, AHA/BHA, Vitamin C, & any exfoliation products should be discontinued 2 weeks prior to your appointment if used around your forehead/the procedure area.

- Laser treatments, chemical peels, waxing, & brow tints should be done 2 weeks prior to your appointment.

- Botox & dermal fillers should be done 4 weeks prior to your appointment.

- Skin should be clear of blemishes, non-irritated, & sunburn free for optimal results, especially around the procedure site.**

**If you wake up with a pimple in the brow area, please notify me immediately for rescheduling.
Type your name below indicating that you acknowledge and understand the pre-care instructions.*
Full Name
Policies & Contraindications

Please read my policies below.
Deposits:

Deposits are absolutely NON-REFUNDABLE and NON-TRANSFERABLE

Late Policy:

Please arrive to your appointment on time. If you are running late, please let me know ahead of time.

-All clients are given a 15 minute grace period.
-Anything after 15 minutes will automatically be cancelled.
-If you are run into traffic, please contact me immediately so that I am aware that you will be late.

Cancellations/ Rescheduling:

If you need to cancel or reschedule your appointment, please inform me at least 48 hours BEFORE your appointment.

-If you cancel your appointment, you DO NOT get your deposit back.
-I only allow you to reschedule your appointment ONE time before requiring a new deposit.
-If you cancel less than 24 hours or decide to no call, no show you will be charged 50% of your chosen service.
No Call, No Shows = No Apointments EVER. AND you will be charged a portion of the service you booked
Type your name below indicating that you acknowledge and understand Adored Ink’s policies.*
Full Name
Disclosure & Release Form

Adored Ink appreciates your interest in the new and improved techniques of Semi-Permanent Makeup. You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. Please read the statements below completely and initial to indicate that you have read and understand the following:
CLIENT DISCLOSURE
I understand that no warranty or guarantee has been made to me as a result of this permanent procedure.*
I understand that makeup/camouflage/correction procedure results cannot be guaranteed.*
I realize that there is potential for discomfort during the procedure and healing process, as well as possibility of bleeding, swelling, and allergic reactions to the products used.*
I understand that tattooing is considered permanent and will be a permanent change to my body.*
I understand that a tattoo can only be removed with a surgical procedure, and that any effective removal may leave permanent scarring or disfigurement.*
I understand that hair stroke technique can be used on top of old permanent makeup, but no guarantee can be made on final results.*
I understand that the healing process varies for everyone. Pigment loss or color change normally happens in most cases during the first week. I will stay calm, not panic, and return for touchup session no earlier than 4 weeks, and no later than 10 weeks after initial session (when skin is completely healed). *
I understand that permanent makeup is regulated by the State Board of Cosmetology.*
I understand that Adored Ink has the right to stop contact with me, the client, and may refuse to provide a service for any reason.*
I have been given the opportunity to ask questions about the procedure, the risks, and the hazards involved.*
I believe that I have been given sufficient information to give this informed consent. *
CLIENT ACKNOWLEDGEMENT AND RESPONSIBILITY TO INFORM TECHNICIAN

CLIENT further agrees to indemnify and hold harmless Adored Ink, its governing officer from any claim of liability, losses, damages, or any expenses whatsoever as a result of any claims, demands, damages, costs, or judgements including, but not limited to, claims based on negligence against it, that may arise in connection with the services performed by an independently contracted technician.

This agreement in intended to be an addendum to any previous conditions, releases, or hold harmless agreements, in written form, verbal, or manually communicated between Adored Ink and its client in connection with permanent makeup procedures. The CLIENT will be given a copy of this agreement prior to the permanent makeup procedures being performed and has been given the opportunity to attain reasonable understanding of this agreement, including the opportunity to ask questions, either by written, verbal, or manual communication prior to the signing of this document.

As a client, you have the responsibility to inform the technician of all possible concerns. Please read the following and initial after each statement.
I understand that I must inform the technician of all medications being taken by me, even though I have it written on my Medical History Form. For example, pain control medicine, such as Aspirin, may cause the blood to thin, and excessive bleeding may occur.*
TYPE INITIALS
I understand that it is my responsibility to advise the technician of any concerns I may have before they being the procedure, even though I may have written it down on the form.*
I am free from drug and alcohol use or any other substances.*
I am not pregnant or breastfeeding.*
I have no known allergies to dye, nickel, or any topical anesthetics.*
I understand that the tattoo ink/permanent cosmetic pigments have not been approved by the FDA and that the health consequences of using these products are unknown.*
I understand that taking before and after pictures is a condition of such procedures. I hereby forever release and discharge Adored Ink from any and all claims, actions, and demands arising out of said photographs for websites and social media.*
I have read and understand aftercare treatment instructions and recommendations, and I understand my responsibility to follow them to ensure proper healing of treated area. *
Today’s Date*

MonthDayYear
Date
Signature*
Personal & Medical

Please fill out fully and specifically as possible.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Are you 18 or older?*

YesNo
Gender*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Medical History

Please Check all that apply to you
General Health*

NonePregnant/NursingAnemiaHepatitisLupusCancerHIVSeizure/DizzinessAlopeciaAsthmaEye ProblemsHeadachesArthritisCardiac Valve DiseaseOther (Please Explain)
Please Explain:
Skin Health*

NoneMolesRosaceaScarsAcneVitiligoPlastic/Cosmetic SurgerySkin CancerBirthmarksHistory of KeloidsOther (Please Explain)
Please Explain:
Skin Products/Treatments Used*

Retin-AAccutaneChemical PeelsNoneOther (Please Explain)
Please Explain:
Skin Type*

Dry/Normal SkinOily SkinCombination SkinNot Sure
Medications*

NoneVitamins/HerbsAspirinIbuprofenBenadrylHormonesHeart PillsPain PillsBlood ThinnersInsulinThyroid MedicationOther (Please Explain)
Please Explain:
Allergies*

NoneCodeine/DemerolPenicillin/SulfaHair ColoringBee Sting/Insect BitesMakeup/MascaraSunscreens w/ PABA PillsNickelLatexOther (Please Explain)
Please Explain
Do you take medication daily?*

YesNo
Do you have a history of herpes infection at the procedure site?*

YesNo
Are you allergic to latex?*

YesNo
Do you have a history of hemophilia or other bleeding disorders?*

YesNo
Do you have tattoos?*

YesNo
Do you heal normally?*

YesNo
Any prior collagen induction?*

YesNo
Do you have any prior permanent make-up?*

YesNo
Are you wearing any eye contact lenses?*

YesNo
Are you pregnant, breastfeed, or nursing? (Female)*

YesNo
Artist may use my photo on social networks, publications, portfolio, and/or displays.*

YesNo
Have you had Botox on your forehead within 4 weeks of the appointment date?*

YesNo
Do you have any other health problems or medical conditions that was not listed above?*

YesNo
If you answered yes to the last question, please explain here:
I have filled out my medical history form fully and truthfully to my knowledge.*
Print Full Name
Signature*
Today’s Date*

MonthDayYear
Date
Technicians make no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent make-up applications. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible reasons for restricting you from receiving a tattoo, you must approve of the procedure and the color before the application of your permanent make-up.
Authorization
I confirm that all information given in this form is true, complete, and accurate. I released this organization for any responsibility in case of accident, illness, or injury. I understand that with time the pigment can fade and will change according to metabolism, skin type, medication, age, smoking, alcohol, sun exposure, Retin-A and Glycolic acids. I understand that the process used to apply color is not a one step process and may require subsequent visits to achieve desired results. I further understand that the fee includes my first visit and one touch-up visit within two months of first appointment and the result of the procedure will be a permanent change I understand the nature of the procedure and possible complications, reactions or adverse effects that may occur as a result of the applied pigments. I fully understand this is a tattooing process, and have discussed any medical conditions I acknowledge that no assurance was offered about the outcome. I have read through the Highlight on the AdoredInk Instagram page and agree to strictly adhere to such instructions. I understand that taking before and after pictures may be required and allow Adored PMU to use the photos for marketing or promotional services. I acknowledge by signing below, that I have been given the full opportunity to ask any and all questions which I might have about obtaining this procedure(s) from, Adored Ink. I also acknowledge that all of my questions have been answered below to my full and total satisfaction. I specifically acknowledge that I have been advised of the fact and matters set below, and I agree as follows.
I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Adored Ink shall perform permanent application of dyes to the skin of the releaser. Whereas releaser has been informed as to the methods and procedures concerning the result of such treatments, a scratch test will aslso be performed prior to the procedure, if requested by the client, to detect any signs of allergies. I hereby release, acquit and discharge Adored Ink and any and all persons which are or might be claimed to be liable to me from all claims and demans or whatever nature, actions and causes of action, damages, cost, loss of service, expenses and compensation on account or in any way growing out of personal injuries and property damage to result at any time in the future, whether or not they are in contemplation of parties at the present time and whether or not they arise following the execution of the release as the as the result of treatment procedure rendered. Releaser agrees to indemnify the hold harmless of Adored Ink for any loss, damage, claim, injury, or expense asserted against myself.
Signature of the Client*
Date*

MonthDayYear
Date
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to be spread mainly from person-to-person contact. As a a result provincial and federal health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups and people. Adored PMU has put in place preventative measures to reduce the spread of COVID-19 with strict cleaning measures and a strong recommendation to wear masks during appointments if possible. Further, attending to appointments in the studio could increase your risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 by attending the appointment and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed or infected by COVID-19 at Adored Ink may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my family may experience or incur in connection with my attendance at Adored Ink.
Date*

MonthDayYear
Date
Signature*

Photography Consent & Release Form
Consent & Release Agreement

All permanent cosmetics use the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with the body fluids are disposable and disposed after use. Health department regulations are STRICTLY adhered to

Generally, the results are excellent, however, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed. Sometimes a third session is necessary

Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7-10 days, the color will fade 30-40%, soften and look more natural. Microblading pigment is semi-permanent and will fade over time and will likely need to be touched up within 6 months to 18 months. Please note that color may fade faster on oily skin or skin with large pores.

Photography Release Consent

Adored Ink would like your permission to use these photos for advertising. For example, in portfolios, online and in print ads, etc. They are also needed for insurance purposes. Your consent is necessary regarding this.
Please Choose*

Yes, any and all pictures/videos - full face includedONLY close ups of brows
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(s) and I have had the opportunity to ask questions and all of my questions have been answered. All information is true and accurate to my knowledge: lying about anything may result in risk or hazard to me, the client. Adored Ink is not liable for any falsification on these records. I acknowledge that I have reviewed and approved the material given to me, and the technician and Adored Ink to perform on my body, the PMU procedure desired today.
Name*

First NameLast Name
Signature*
Today’s Date*

MonthDayYear
Date
Email (If you would like a copy of these forms, please input your email here)
example@example.com

Policies & Contraindications

Please read through following statements fully and INITIAL after each statement to indicate that you fully understand my policies.
I have read through all contraindications and policies before booking this service. Located here: adoredbysav.as.me*
INITIALS
I understand that a $50 NON-REFUNDABLE and NON-TRANSFERRABLE deposit is required to secure my appointment. *
I understand that if I do not follow the pre-care instructions before coming to my appointment, my appointment will be cancelled. I will lose my initial deposit and will be charged 50% of my chosen service.*
I understand that I have a 15-minute grace period to notify my artist that I will be late or I risk my appointment being cancelled and being charged 50% of my chosen service.*
I understand that I have up to 48 hours before my appointment to cancel or reschedule my appointment without a charge penalty.*
I understand that if I do not show up to my appointment and I do not call or text my artist, I will be charged 50% of my chosen service and I will no longer be able to book any future appointments.*
I understand that failing to follow the recommended aftercare instructions will result in poor retention for which Adored Ink is not responsible for and any additional touchups may be required at a cost. *
Should be Empty:

ADORED PMU

Pre-Care Instructions

Policies & Contraindications

Disclosure & Release Form

Personal & Medical

Medical History

Authorization

Photography Consent & Release Form

Policies & Contraindications