PMU& fine-line consultation form

ANJA GOSHA
Office No 4, Third Floor
Cambrian Buildings
West Bute Street CF105FL
anjagosha@gmail.com
www.anjagosha.com
07841433508
PMU& Fine-Line Tattoo Consultation Form

Please complete all fields.
Customer name*

First NameLast Name
Email *
example@example.com
Address*

Street Address

Street Address Line 2

City

Postcode
In case of emergency please contact:*
Please provide name and phone number
Family Doctor Name and Address *
What is your skin condition? *
Please explain in detail-especially in the area where treatment will commence.
You must be at least 18 years old to receive treatment. Please provide your date of birth and bring a valid ID to your appointment for verification.*

MonthDayYear
Date of birth
Do you suffer with any allergies or intolerance?*
Please explain
I First Name Last Name understand that I could have an allergic reaction to used products within 24h. I know that if an allergic reaction is evident within 24h that it is not to be constructed, I may not react at some time. I affirm that it will release the technician from liability for an allergic reaction should I wish to proceed with treatment.
A patch test is not required for fine-line tattoos. Date (Patch test date)
Do any of the following apply to you? Please tick.*

Are you under the influence of drugs or alcohol?Are you pregnant or breastfeeding?Do you have epilepsy?Do you have haemophilia or blood clooting disorder?Do you have diabetes?Do you take Roaccutane or any other medication for a skin disorder?Do you take Antabuse?Do you wear contact lenses or suffer from glaucoma?Do you currently have a cold sore, fever blister or any other skin disorder on the area; the area has been free from any such infection for not less than 21 days? Do you understand that lip procedures may stimulate any dormant viruses such as herpes (cold sores) and this is a risk of treatment that you will accept and will not hold the Company liable for? You will have to follow the NHS recommendations set out in relation to such viruses.Are you undergoing any radiotherapy or chemotherapy treatment at present or have had any previous radiotherapy or chemotherapy treatment that came to an end not less than 42 days ago from the date of this declaration?Are you allergic to any local anaesthetics?Do you knowingly have any infectious disease which could prevent you from having this procedure done?Do you have any heart conditions such as angina or blood pressure problems?Do you have prosthetic heart valve/ congenital heart disease?Do you have peacemaker in situ?Are you taking any anticoagulants to prevent blood clots?Do you have any skin problems such as psoriasis or eczema/ dermatitis?Do you have lumpy/ raised scars(hypertrophic/ keloid scars?Have you ever had an anaphylactic reaction (requiring hospitalization and or adrenaline)?Do you have any known alergies to plasters/creams/metals/iodine/shellfish/latex/food stuffs?
Any medical conditions not mentioned above?*
Please explain in detail.
If you answered "yes" to any of the question above, please provide a detailed explanation below*
Do you take any prescribed medication? *
Please explain in detail.
Do you take any medication that affects your immune system such as "immunosuppressive treatments (example cancer treatment such as chemotherapy), high dose steroids or treatment used for inflamatory conditions? *
If yes, please explain in detail.
Are you prone to "fainting attacks"?*
If yes, please explain in detail and state trigger
Is there anything else you would like to inform us of before your treatment begins?*
If yes, please explain
Have you applied a topical anasthetic in advance of receiving special procedure? *
If yes, please explain
What are your expectations regarding treatment?*
Treatment booked*
Do you have any permanent makeup or tattoo already/ fine-line tattoo? *
Please explain as much as possible.
Photo Requirement for Permanent Makeup To ensure the best possible results, all permanent makeup clients—whether new or returning—must provide a clear photo of the area to be treated (eyebrows, lips, or eyeliner). This helps me assess your skin and plan your treatment accordingly.
Please upload a picture without any make-up
File Upload*

Cancelof
How did you hear about me?*
Google, social media etc?
To follow this procedure, you must agree to and adhere to the statements below. Please inform your technician if the statements do not apply to you or are false to you as an individual:

I have not undergone botox treatment or any other surgical or non-surgical treatment within the last 14 days and written notice of any planned botox, surgical or non-surgical treatment has been given to my Technician. (Only Pmu).

The general nature of the procedure has been explained to me, and I am fully aware of consenting to this said procedure.


I have chosen to undergo a procedure which is not medically necessary.

I understand that medical tattooing is a process with healing variables so the healed colour cannot be guaranteed.

My chosen colour once implanted will initially look much darker.

I understand that all colours will fade and alter with time, this is why it is advisable to have a retouch every 12 to 14 months depending on the individual. Only Pmu.

I understand that after each treatment there may be swelling, or in some cases bruising to the area. I may experience discomfort during the procedure and possibly some pain, but my technician will endeavour to make it as comfortable as possible and will reassure me throughout the process.

I understand that going forward after this treatment plastic surgery, laser treatments and any enhancement procedures may alter my permanent makeup or tattoo.

I understand that I will be given aftercare instructions and I must strictly adhere to these.

My technician has discussed with me possible outcomes and recommended a treatment plan. I will require at least 2 visits to complete treatment- in some cases 3.

I understand that I have received pre and post-procedural instructions and I will strictly adhere to all instructions and advice. I understand that my failure to do so may jeopardise my chances for a successful procedure and it may result in causing an infection which would be entirely my fault and I cannot and will not hold my technician or the company liable.

I understand that this is a tattoo process and therefore not an exact science, but an art.

I understand and consent to clinical photographs being taken to document before and after the procedure.

Signature*

In some cases, I would like to show before/after or just after treatment on social media.
Examples of the pictures which will be shown to promote my business and me as the artist are below.
     Yes I agree for this type of the pictures to be shown on social media.    No, thank you *
I   First Name*   Last Name*   understand that my chosen colour of pigment may be modified slightly, due to the tone and colour of my skin. My technician will endeavour to explain and advise on the colour being chosen with regard to my skin tone and the colour I would like to achieve. I request to have the permanent skin pigmentation procedure and accept the permanence of the treatment as well as the possible complications and consequences of the procedure. Only pmu.
Tattoo is only in black colour.
I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation I understand the permanent skin pigmentation procedure has known and unknown complications and consequences including but not limited to infection, scarring, inconsistent colour, and spreading, migrating, fanning or fading of pigments.
I understand I can email you with more specific questions at anjagosha@gmail.com any time before the procedure can commence.  Signature*
Pre-treatment advice for PMU

Lips

If you have a history of cold sores (herpes simplex) and are scheduling a lip tattoo we advise you to use anti-herpes medication for example Zovirax ointment that can be obtained from a chemist. Use the preparation 1-week prior and 1-week after your enhancement 5 times a day to reduce the incidence of the outbreak by 50%. Oral anti-herpes medication (Acyclovir) will control the incidence of an outbreak more or less completely. PMU does not cause cold sores, however, if you carry the virus, it lays dormant in the nervous system and can be aroused by the infusion process.

IPL laser hair removal around the mouth should be done no less than 2 weeks before your procedure.
Waxing and bleaching treatments should be performed no less than 2 weeks before your procedure.

Electrolysis treatments should be performed no less than 2 weeks before your procedure. Dermal fillers in the lip should be performed no less than 4 weeks before your procedure. Permanent makeup adds colour to the skin so expectations must be managed.
Prepare to drink through a straw for a few days after

Lightly exfoliating your lips to remove dry dead skin will help with better retention Keep your lips moisturised - do not turn up to the appointment with chapped lips Bring in your favourite lip colour for everyday wear to your appointment.

Eyebrows

Waxing and threading treatments should be performed no less than a few days prior to your procedure.
IPL laser hair removal should be performed no less than 2 weeks prior to your procedure. Electrolysis treatments should be performed no less than 2 weeks prior to your procedure. Eyebrow tinting should be performed no less than 4 days prior to your procedure – best to keep your natural colour brows so Jasmine can see this

Eyebrow hair stimulating products should not be used for 2 weeks prior to your procedure. Botox in the brow region should be performed no less than 2 weeks pre-procedure (you can have this treatment after the PMU immediately as long as the injection site is not in the eyebrow

Excema or Pharisees in the eyebrow region must be avoided. The eyebrow skin needs to be a good healthy canvas for us to work and implant colour
If you have any moles or raised scars on the eyebrow we need to avoid this patch too as we cannot work over these

Avoid coming to your appointment with heavy makeup on as we will have to cleanse and remove the makeup resulting in scrubbing the skin and causing sensitivity
Avoid sun beds 2 weeks before and post-procedure.

Eyeliner

Eyelash tinting or eyelash perming treatments should be carried out no less than 4 days prior to your procedure.
Eyelash stimulating products should not be used for 2 weeks prior to your procedure. Artificial lashes should be removed prior to your procedure and not reapplied for 2 weeks post-procedure.

Do not wear contact lenses during or immediately following your procedure. Remember to bring your glasses. You may resume wearing your contact lenses 24 hours after the procedure.
You may have mild swelling after your tattoo procedure and as a safety precaution, you may wish to have someone drive you home.
Please confirm:*

Yes, I understand
Fine line tattoo

Try to get a good night sleep before the session this will help you sit well during the Tattoo.
Don't be tempted to have a drink the night before or on the day, Alcohol is a blood thinner, which means you will bleed more and the ink won’t take so easily.
🙃Ink stains - please don't wear your favourite clothes for the session just in case,
Anti-coagulants lengthen the time it takes your blood to clot, Anti-platelet drugs such as Aspirin and Ibuprofen prevent your blood from clotting, causing the tattoo to bleed more making the experience less comfortable. Please note that coffee and energy drinks can also thin the blood.

* Please check with your GP if you are prescribed medication.
Paracetamol reduces pain and helps reduce inflammation so if your worried take two before or after the session. Arnica is a natural pain relief which you can take leading up to your tattoo session.
Have a good breakfast on the day of your tattoo, this increases your stamina as getting tattooed burns a lot of calories.
Bring a sugary drink for your session. Blood sugar levels drop when you're getting tattooed so this can help you feel more comfortable during the session, this also allows us to pause less frequently, which can interrupt Adrenaline build up, making it harder to cope.
Drink lots of Water- before and during the session - proper hydration allows the skin to accept the ink more easily, without thinning the blood.
Consider a distraction, music to listen to or a book or simply flicking through your phone will help, its best not to focus on the tattoo itself
I don't advise numbing the area, however there are local anaesthetic creams that are FDA-approved and specifically designed to alleviate and numb the pain of getting tattooed. If you are going to use an anaesthetic, check out the brand HUSH, which comes in a gel, spray and foaming soap to help numb the pain before the session *please note application of these are at your own risk as they could compromise the quality of your tattoo. Everyone's skin reacts differently to these creams and they can make it more difficult to tattoo, they can also affect the healing of the tattoo, also be aware they don't last for a long time and don't always help much.
Please try to have clean sheets on your bed, and wear clean clothes as your tattoo will be open for the first week, everything it touches has the potential to cause cross contamination if unclean.
Understanding the application process;
Pigment will be applied under my skin using a series of needles,
This will result in a permanent mark and scar to the skin, this wound will be open at first and need dedicated care for some weeks following the application. This will result in a permanent scar to the skin that will never fully recover,
Skin reactions including but not limited to bumps, allergic reactions to the ink, burning or swelling or minor obstructions when getting MRI scans, infections, missing signs of skin cancer, blood borne infections, emotional distress (due to the release of endorphins, this can result in a surge of emotion triggering buried feelings to rise, this can happen immediately or over some weeks following application of the tattoo )

Art Form

I understand tattooing is an art form of which there are many variables, I trust that my practitioner takes measures to monitor as many variables as possible (e.g., she adjusts application techniques for each person depending on their skin, she discusses each design prior to application, she makes previous examples of her work available to view as a guide to her working style)
I understand that everyone’s skin and health is different which can alter the finish of the tattoo and healing period, our taste is subjective and the outcome of a semi-permanent tattoo can never be guaranteed.
My practitioner has discussed my design with me and I am happy to proceed based on this conversation.

Responsibility

I waive and release to the fullest extent permitted, my practitioner at AnjaGosha Studio from all liability whatsoever from all claims that I may have for personal injury or otherwise, resulting in the application of tattoos applied by my practitioner at the registered premises cf105af 54A

Suitable Hygiene

I understand my practitioner and the ‘AnjaGosha Studio' premises team have all appropriate certifications from local Environmental Health Departments and my practitioner also has an up to date Infection Control & Prevention’ certificate. I trust my practitioner uses all appropriate medical grade cleansing solutions and applies necessary cleansing practices in order to keep the studio area and myself as the client as safe as possible, I acknowledge that every care will be taken to ensure optimal hygiene procedures are followed but that there is no absolute way to guaranteed our safety, tattooing is always a risk to the clients health.

Permanent changes

Understanding the application process;
·Ink will be applied under my skin using a series of needles,
·This will result in a permanent mark and scar to the skin, this wound will be open at first and need dedicated care for some weeks following the application. This will result in a permanent scar to the skin that will never fully recover,
·Skin reactions including but not limited to bumps, allergic reactions to the ink, burning or swelling or minor obstructions when getting MRI scans, infections, missing signs of skin cancer, blood borne infections, emotional distress (due to the release of endorphins, this can result in a surge of emotion triggering buried feelings to rise, this can happen immediately or over some weeks following application of the tattoo )Black and Grey can become blushing over time, as the ink degrades slightly and is muted by the tone of your skin , colour ink has this same degeneration also but to various tones.

You will be asked to confirm your full name, date of birth, complete a health questionnaire, provide a valid photo ID and sign the form electronically.
Yes, I understand
Post-treatment advice

For two to five days after the treatment, the procedure area may experience the following symptoms:

Flaking, tenderness, dryness and itching, swelling, redness, eyelashes may stick together and eyelids may appear red and puffy after any eye procedures.

For at least 5 to 7 days after the procedure or until the area appears to be healed, including the following in your daily routine:

Apply the provided cleansing and moisturising balm at least 2 times a day using a clean cotton bud each time (to avoid infection)

*If you have ever had cold sores or herpes simplex in the past it is important that you continue to use medication for 7 days after your lip treatment, as you did 7 days before. This will help prevent an outbreak, which causes discomfort and could result in scarring.

Eyebrows

Blot gently with damp cotton wool to remove any residue
Use a fine layer of the given moisturising ointment 2 times a day or as needed Do not tweeze for at least up to a week after the treatment

Lips

Apply moisturising ointment 2 times daily or as needed
It is advisable to use a straw to drink fluids immediately after the treatment Blot gently with a damp cloth if the area gets wet

Eyeliner

It is advised not to use any aftercare cream on the eyes. However, a saline solution may be used to bathe the eyes if they are feeling tight or sore

Important Do Nots

Do not expose the area to any extreme temperatures. This includes sunbathing, tanning beds, saunas etc.

Do not use make-up for at least 3 days and if you have had an eyeliner procedure, it is advisable to buy a new mascara to prevent any infection

Apply moisturising ointment 2 times daily or as needed. Always use fresh and clean cotton pad or a finger.

It is advisable to use a straw to drink fluids immediately after the treatment Blot gently with a damp cloth if the area gets wet

Do not pick, scratch or rub the area or the colour will heal unevenly or cause scarring and infection

Please Note:

The colour will be 50% darker straight after the treatment. It will fade after 4 to 7 days and the true colour will not be visible until the area has completely healed and a time of up to 4 weeks has passed.

In order to keep your permanent makeup in perfect condition it may be necessary to have a follow-up/retouch appointment every 12 to 14 months, but this will vary with each individual.

If you are planning an MRIScan, Chemical Peel or any similar procedures, please inform our practitioner that you have had permanent cosmetics.

Laser hair removal can fade and change the shade of your lip or brow procedure, always advise the laser technician that you have had a permanent make-up procedure.

*The area may feel tender for a few days after the procedure.
Follow my business on Instagram
Signature*

Powered by Jotform SignClear
By signing this document, you declare that the information given is correct and complete and you consent to proceed with treatment.
Date*

MonthDayYear
Date
Should be Empty:

PMU& Fine-Line Tattoo Consultation Form