PMU Consent Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Email

Date of Birth

mm-dd-yyyy

How did you hear about us?

Social media handles

Instagram, Facebook

Emergency Contact

Full NameCell Name

48 hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. Any corrections to the area will be made at the Follow-Up appointment. Fees may apply. By initialing here, I’m acknowledging I have read, understand, agree with the terms of these policies.

The nature and method of the proposed permanent cosmetics procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur.

By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:

(Please mark YES after you clearly understand each statement)

I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.

I acknowledge that complications as a result of permanent cosmetics procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.

I realize that my body is unique and neither the company can predict how my skin may react as a result of the procedure.

I have previously had permanent cosmetics performed by someone other than our company on the same area (brows, lips, etc) that I am asking to work on today.

IF YES to above, I understand that correcting or touching up permanent cosmetics that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which the company has no control. I understand that additional appointments after the initial and followup appointments may be required, and will be billed at the company's standard rates. I understand that the company can not predict the results in advance and can not guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold the company harmless from same.

I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.

I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my permanent cosmetics, and that I must inform any future service provider that I have had permanent cosmetics applied. I understand and accept that such changes are not the fault of the company. I further understand that such changes or degradation in my appearance may not be correctable through further permanent cosmetics procedures.

I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.

I acknowledge that obtaining the permanent cosmetics is my choice alone. I consent to the procedure and to its attendant risks, and to any actions or conduct of the company reasonably necessary to perform the procedure.

I understand that I will have the opportunity, within the time constraints of my appointment, to approve the design and color of the permanent cosmetics to be applied, and I accept responsibility for same.

I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of the company.

[Optional/Requested] I consent to Array Esthetics & PMU using “before & after” photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting the company, which will then discontinue use of said photo(s).

I have been given the full opportunity to ask any and all questions which I might have about obtaining semipermanent cosmetic procedures from a permanent cosmetics specialist at the company and that all of my questions have been answered to my full and total satisfaction.

If you have had previous permanent cosmetics performed by the company, has your medical history changed since you last filled out our Medical Profile form?

If YES, please specify.

Type N/A if it doesn't apply

I understand that there are no refunds on services rendered, including all permanent cosmetic procedures, at our company.

Confidential Medical Profile

To Avoid Unforeseen Complications, Please Answer The Following Questions

Please list any known allergies:

Including adhesives, glues, tapes, bandaids, etc. or N/A

Are you under 18?

Are you currently sick with a cold, flu, or any other type of sickness/illness?

Have you ever had any permanent cosmetics procedures before?

Do you currently have Botox, Dysport, Juvederm, or any other injectables/fillers?

If so, in which areas and when was your last injection?

Do you have a history of cold sores, herpes, or fever blisters?

If yes, are you currently taking prescription medication for it?

If so, for how many days?

Are you allergic to any metal?

Have you had any ibuprofen, aspirin, or blood thinners in the past week?

Are you sensitive/allergic to latex?

Is there any history of skin diseases or remarkable skin sensitivities?

Have you had a chemical peel or laser?

If so, when?

Do you have problems healing?

Are you pregnant or nursing?

Are you currently undergoing radiation or chemotherapy?

Are you required to take antibiotics during dental or invasive medical procedures?

Are you currently using any retin-a or alpha-hydroxy skin care products?

Previous problems with tattoos or has your physician advised you not to have a tattoo at this time?

Any mood altering drugs within the last 8 hours?

Are you on any immunosuppressive medications such anti-inflammatories or steroids?

List all medications you are currently taking:

N/A if none

Please check any of the following that may apply to you.

List any other medical conditions or issues not addressed above:

N/A if none

Primary Physician’s Name:

Primary Physician’s Number:

Format: (000) 000-0000.

By signing below, I acknowledge, understand and agree that:

We do not practice medicine, does not accept health insurance, and have made no representation to the contrary.
The information provided on this form is accurate and complete to the best of my knowledge, and that the company is not responsible for complications or problems arising from any incorrect or omitted information;
Some individuals will have complications related to permanent cosmetics. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold the company and its employees and contractors harmless for same;
We will use the information provided above to assess my suitability for the proposed permanent cosmetics services.

48 hour notice is required for any canceled or rescheduled appointment or up to 100% of service price will be charged. Failure to show without notice will require in full payment of service booked. We do not offer monetary refunds on services rendered. Any corrections to the area will be made at the Follow-Up appointment. Fees may apply. By initialing here, I’m acknowledging I have read, understand, agree with the terms of these policies.

Fitzpatrick Skin Type Quiz

This information will help us better evaluate your skin type so that we can choose the proper technique and color for you. The skin type is often categorized according to the Fitzpatrick skin type scale, which ranges from fair (skin type 1) to dark brown (skin type 6).

Please select all of the following that apply to you.

Signature

Permanent Makeup Informed Consent

Our Policies