PMU Consent

General Consent and Procedure Permit
Clients Full Name
Address
DOB
Phone
I hereby authorize Alyssa Williamson to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises in the course of the procedure(s) I further request and authorize her to use her full judgement and do whatever she deems advisable and necessary in the circumstances.

I understand that permanent cosmetic enhancement is an advanced form of tattooing, l accept responsibility for determining the color, shape, and position of the enhancement as agreed during the course of my consultation.

I understand that a sensitivity test for pigment does not guarantee that I will not have anallergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs. I am aware that a sensitivity reaction to anestheetics can occur and accept all responsibility to allergic response.

I fully understand and accept that non- toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over the course of 1-3 years. Even though the color has faded the pigment will stay in the skin indefinitely and may leave a light residue of color. I understand that dyes, ink,s and pigments are not approved by the Food and Drug Administration and the health effects are not known.

l accept that the highest standards of hygiene are met, and that sterile disposable needles are used for each individual client, procedure, and visit. 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. l understand that this is why I need to return for a touchup that is not included in the initial price. Tunderstand that the touchup, if required, will be performed 3 months after the initial procedure and that after a 3-month period I will be charged an additional fee for any procedures. l understand that a touchup takes place 6-12 weeks after the initial application to allow the procedure site to fully heal. I will book the appointment when it is convenient for both parties.
For the purpose of documentation, I also consent to the taking of "before" and after" photographs of said procedure(s) If the treatment is discounted on an offer price give my consent for just the area (no full face) before and after pictures to be used for marketing.

I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL.
I have read an understood the above information.
Client Name
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Subject to, the agreed design being shown to myself, as well as digital photographs I sign to say this is a true picture of the template of what design is required. I sign also to digital photos being taken immediately after my treatment so that there is a true comparison between what was requested and what was delivered.
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"I declare that I give my full consent to the tattooing being carried out by the aforementioned practitioner. I confirm that potential complications. e.g. infection and swelling, for the procedure undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and agree that it is my responsibility to read this and follow the instructions on it. Until the site has healed. I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, and that I am over the age of consent for this procedure (i.e. 18 years old for tattoos) and that I am not currently under the influence of alcohol or drugs.
Signatures of Client
l understand that the pigment may migrate under the skin, however this is a rare occurrence. I understand that permanent cosmetic enhancement is an invasive procedure and the infusion process can be uncomfortable. I understand that loss of any eyelashes during the healing of permanent cosmetic eye enhancements will result in new eyelash growth over a 4 month period and that evelash loss is rare and minimal.

I am aware that the result of the procedure is determined by the following Medication, Skin Characteristics i.e. dry/oily /sun damaged, Natural skin undertones. Alcohol intake and smoking, General stress, A compromised immune system, poor diet. Post procedure care treatment.

I have been advised that upon completion of the procedure there may be swelling and redness of the skin. which will subside within 4 days dependent on lifestyle. In some cases bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited for up totwo weeks following the infusion process.

l understand that immediately after the procedure the enhancement can be 30 to 50% darker than the desired result and can take between 7-10 days to lighten. l understand that the true color will be visible 1 month after each application. And that the color may vary according to skin tones, skin type, age and skin conditions l appreciate that some skins accept color more readily than others and no guarantee of an exact effect or color can be given.

i am aware that if l have had previous outbreak of cold sores/herpes and receive a lip enhancement I may have an outbreak again following the procedure. I have been made aware that anti herpes medication over the counter or a prescription and has been shown to prevent or minimize such outbreaks.

I am aware that that if have had previous eye disorder or eyeinfection and receive an evelash enhancement, the disorder may reocour again. l agree to use the correct medication to prevent such a disorder reoccurring. I am aware that even though my vision is not affected by permanent cosmetic eye enhancements maywish to have someone drive me home.

l understand that I may experience dry lips for up to two weeks following permanent cosmetic lip enhancement.

l agree to inform my doctor of my permanent cosmetic enhancement if require MRI scan within a 3month period of receiving the procedure.

l agree to follow all pre procedure and post procedure instructions as provided and explained to me by the practitioner. I understand that infection and possible scarring car occur if l do not adhere to the said instructions.

To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being direct or indirect result of my decision to have the procedure done at this time.

I am atleast 18 years old and I am not under the influence of drugs or alcohol.
Occupation
List all the medications you have been taking in the last 6 month
Have you had any of the following in the last 2 days: Asprin, Ibuprofen, Alcohol?
Have you received Chemo or Radiation Treatment in the last year?
Name of Doctor
Surgery within the last 6months
Allergies have you ever had an allergie reaction toany of the following:
Allergies have you ever had an allergies reaction to any of the following:

NutsMetalsOintmentsPaintsLatexHair DyesOther
Doyounumb well witha dental injection to numb your mouth? Are youpresently pregnant or breast feeding?

MRI scan scheduled in the next 3 months Laser or IPL scheduled in the next 3 months
Do you numb well with a dental injection to numb your mouth?
Are you presently pregnant or breast feeding?
Prior to dental procedures do you receive antibiotic therapy ?
Please check if you answer YES to any of the following:

Abnormal Heart ConditionCataractsAnaemiaDiabetesArtificial Heart ValvesHeart MurmurPacemakerCirculatory ProblemsMitral Valve ProlapseHemophiliaProlonged BleedingCancerCold Sores(Herpes Simplex)Thyroid DisturbancesPalpitationsProsthetic Hip or JointThricollomaniaNarcolepsyLow Blood PressureSteroidsWatery EyesOccular HerpesGrowths or CystsChapped LipsUse of Sun BedTan RegularlyShinglesKidney DiseaseAlopeciaEyelid SurgerySeizuresStomach UlcersStrokeGlaucomaDo you suffer from eye infectionsLupusHepatitisHivImpetigoHigh Blood PressureOily SkinEpilepsyAcutane in the last 6 monthsBotox in the last 2 weeks?Other TattoosTuberculosisFainting or Dizzy SpellsBruise or Bleed EasilyDo you scar in a raised manner?Liver DiseaseTumorsDermal FillersRecent Hair LossRetinal within 6 months
Others conditions
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Thank you for choosing me for your PMU services!
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General Consent and Procedure Permit