Jemma Jarman PMU

Jemma Jarman

Permanent Make Up
Client Name*

First NameLast Name
Date of birth *

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Medical History Data
Do you have any of the following conditions?

HypertensionHeart issuesRashesDiabetesProblems healing woundsIssues blood Clooting or history of hempheliaHistory of keloid scarringHistory of cold sores or fever blistersHistory of anemiaSeizureSpinal Cord IssuesHistory of skin disease or skin sensitivity
Are you currently taking any medication? Or have any other medical condition? If yes, please list them below:*
Do you wear contact lenses?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Have you had botox or filler within 4 weeks of the appointment date?*
How did you hear about me?*
Technicians make no attempt to, or claim to, practice medicine. Some individuals will have mild swelling & redness related to permanent make-up applications, this will last only a few days. If you are healthy and there are no medical reasons for restricting you from receiving a tattoo, you can safely approve of the procedure, design and the color before the application of your permanent make-up.

Jemma Jarman has provided a patch test which I can confirm has been completed. The patch test demonstrated no reaction when my forearm was perforated & pigment & topical aneasthetic applied to the broken skin.

I confirm this was completed & no reaction occured.

I have read through the Frequently Asked Questions on jemmajarman.com website and agree to strictly adhere to advice & instruction.

I understand that taking before and after pictures may be required and allow Jemma Jarman 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 Jemma.

I acknowledge that all of my questions have been answered below to my full satisfaction. I specifically acknowledge that I have been advised of the fact and matters set below, and I agree as follows.
Authorisation

I consent to all detailed on this form.
I confirm that all information given in this form is true, complete, and accurate. I release Jemma Jarman of 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 my 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 have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal disclosures.

I understand that withholding information or providing misinformation may result in contraindications and or irritation to the skin from treatments received.

I am aware that it is my responsibility to inform Jemma of my current medical or health conditions and to update this history during the course of treatment.

The treatments I receive here are voluntary and I release Jemma & A New You Clinic from liability and assume full responsibility thereof.
Signature of the Client*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

Jemma Jarman

Medical History Data

Authorisation