Porsh Feast PMU form

Patient Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Emergency Contact Person

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

Do you have any of the following conditions?

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

Are you under the age of 18? yes or no

Have you had botox in your forehead within 4 weeks of the appointment date?

Are you currently taking any medications? If yes, please list them below:

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.

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 Frequently Asked Questions on the byporsh.com website and agree to strictly adhere to such instructions.
I understand that taking before and after pictures may be required and allow byporsh 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

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.

Signature of the Patient

Date

Porsh Feast

Medical / History Data

Authorization