PMU and Skin

Permanent Make Up Consent Form

Microblading, Brows, Lips, Microneedling, Eyeliner
Client Details
Date

MonthDayYear
Date
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Age
Age
Phone Number

Area CodePhone Number
Email
example@example.com
How did you hear about us? (If referred, please provide first & last name of referral)
What procedure are you having done

Lip Tattoo/ Lip BlushMicrobladingMicroblading/ Microshading ComboMicroneedlingEye Liner Tattoo/ Eye Lash enhancementFibroblast skin tighteningFacialOther

	Yes	No
Currently Pregnant or breastfeeding
Had undergone Botox treatment
Has or any family history of Diabetes
Has Hepatitis A B C D
Had Forehead/Brow Lift
Has a Heart Condition
Had a Brow Lash Tinting
Has Autoimmune disorder
Have Oily Skin
Has, had, or any family history of having Cancer
Do you bleed excessively
Taking or have taken acne treatments in the past 3 months
Difficulty with numbing creams or anesthesia
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc
Any prior cosmetic procedure
Allergies to metals,medications, food, latex, lidocaine etc,
Any diseases other than listed here
Do you use facial care treatments
Did you have alcoholic drinks in the last 24 hours
Have you had any lip fillers
Do you get cold sores? If so, be aware to take your prescribed meds a wk before
Do you take Retin A products
Any skin issues? Hyperpigmentation, or other
Have you been positive for Covid 19 in the past 14 days
Do you have fever, chills, cough or other flu like symptoms

Permanent Make Up Consent Form