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PMU Waiver & Consent Form
Permanent Makeup
Client Information
Thank you for choosing The Laughing Widow for your Permanent Make up experience. Please complete and submit the form below prior to your scheduled appointment. Must have a valid government issued I.D to be presented at the studio on the day of your appointment. MUST BE AT LEAST 18 YEARS OLD
Are you currently a Brass Knuckles Ink Customer?
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Yes
No
Are you applying to be a Model?
*
Yes
No
What PMU Service are you having done?
*
Eyebrows: Microblading/Powder Ombre/Nano
Lips
Scalp Micropigmentation
Have you done previous Permanent Makeup? If yes, when?
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Yes
No
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Month
-
Day
Year
Date
Name
*
First Name
Last Name
Are you a
*
Female
Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Age
*
Birth Date
*
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Month
-
Day
Year
Date
How did you hear about our studio?
*
Please Select
Walk by
Referral
Google
Social Media
Other
Pre-Procedure Questionnaire
To avoid complications, please answer Y (yes) or N (no) to the following questions:
Please be sure to go to our
Pre & Post Care Instructions
available on our website.
FEMALE ONLY: Are you pregnant or nursing?
Yes
No
Have you had BOTOX, injectables and/or chemical or laser peels in the last 30 days?
Yes
No
If so, when?
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Month
-
Day
Year
Date
If so, when?
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Month
-
Day
Year
Date
Have you Aspirin or any blood thinning medications/supplements within the last 7 days?
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Yes
No
If so, when?
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Month
-
Day
Year
Date
Do you have a tendency to bleed excessivly from minor cuts?
*
Yes
No
Check all that applies. Do you have any of the following. If none, select, (NONE OF THE ABOVE)
*
Problems with healing
Fevers blisters or Cold Sores
Allergic to topical antibiotic preparation. (eg. bacitracin, neosporin or petroleum based products
Taking anti-inflammatory medication or steroids
Taking antidepressants or mood altering medications
Taking Accutane Treatment
Skin diseases or skin sensitivities
Rashes, eczema, psoriasis
Keloid or Hypertrophy Scars
Heart Conditions or Cardiovascular disease
Blood-related diseases
Diabetes
Alopecia
Epilepsy/ Seizures of any kind
HIV/Aids
Cancer of any kind
Undergoing Radiation & Chemotherapy
Autoimmune conditions: Rheumatoid arthritis, joint pain, digestive issue
None of the above
Acknowledgment and Waiver
*
I acknowledge that I contractors and representatives of BRASS KNUCKLES INK that I am of the age of (18) or older and that the following information is true and correct.
*
I am not a hemophiliac (bleeder). I do not have diabetes, epilepsy, hepatitis, HIV/AIDS or any communicable disease. I am not under the influence of alcohol and/or drugs.
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I acknowledge that it is not reasonably responsible for the representatives of BRASS KNUCKLES INK to determine whether I might have an allergic reaction to the pigments or process used in my tattoo and I agree to accept the risk that such a reaction is possible. I understand the permanent skin pigmentation procedure carries with it possible complications and consequences associated with this type of cosmetic procedure, including, but not limited to: infection, allergic, reaction, scarring, inconsistent color and spreading, fanning or fading of pigments. I understand this is a tattoo process and therefore not a science but an art. I requested the permanent skin pigmentation procedure(s) and accept the performance of the procedure as as the possible complications and consequences of the procedure(s).
*
I acknowledge that infection is always possible as a result of obtaining a tattoo. Particularly in the event that I do not take proper care of my PMU. I will follow the pre and post aftercare instructions provided to me and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. I agree that any touch-up work required because of my own negligence or skin conditions, will be done at my own expense.
For Lips Only
*
I acknowledge that infection is always possible as a result of obtaining a tattoo. Particularly in the event that I do not take proper care of my PMU. I will follow the pre and post aftercare instructions provided to me and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips. I agree that any touch-up work required because of my own negligence or skin conditions, will be done at my own expense.
*
I acknowledge that variations of color and design may exist between any tattoo approved by me and ultimately applies to my body. I understand that if my skin complexion is dark, the colors will not appear as bright as they do on lighter skin complexions.
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I acknowledge that this procedure is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have any tattoo-related work done at this time.
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I acknowledge that obtaining my tattoo is by my choice alone and I consent to the application of the tattoo and to any action or conduct of the independent contractors and representatives of BRASS KNUCKLES INK necessary to perform the tattoo procedure.
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I acknowledge and agree to release and forever discharge and hold harmless BRASS KNUCKLES INK and all its independent contractors from any and all claims, expenses, damages, liabilities and legal actions from or connected in any way with my tattoo and the procedures and conduct used to apply my tattoo.
*
I acknowledge and understand the taking of before and after photographs are required. I consent to having my pictures to be used for procedure analysis and for portfolio displays as well as advertising purposes on the studio's website and in all marketing materials.
*
I acknowledge and accept that the Tattoo Studio does not offer refunds.
Model Acknowledgment and Waiver
For Models Only
*
I acknowledge and certify that I have read and checked the above paragraphs and have had explained to my full understanding this consent and procedure permit and I will not hold BRASS KNUCKLES INK and the technician responsible for any unforseen condition arising out of the indicated permanent makeup procedure.
Photo Submission
Please submit photo as indicated below
File Upload: Please upload pictures of existing area conditions.
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