Consent Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Procedure/Service
Permanent Makeup
Saline Removal
Brow Lamination
Ear Piercing
Brow Tint/ Wax
Other
Are you currently taking any medications?
Yes
No
What are the medications you're currently taking and what is their purpose?
Do you have any allergies?
Yes
No
Please list down your allergies below (e.g. seafood allergy, Latex, Iodine, penicillin-based antibiotic allergies)
Are you pregnant or Breastfeeding?
Yes
No
Have you eaten within 2 hours of your appointment?
Yes
No
Are you wearing contact lenses?
Yes
No
What type of skin do you have?
Oily
Dry
Combination
Please check below if you have or had any of the following:
Rows
Yes
No
Remarks
Cancer or Cancer Treatments
Hyperpigmentation
Keloid
Heart Condition
Diabetes
Hepatitis ABCD
Autoimmune Disease/ Lupus
Any Skin Treatments
Any Blood Thinners Such as Ibuprofen, Aspirin, Alcohol, Excedrin ect
Retinol Skin Products
Covid or flu like symptoms
Accutane in the past year
Rosacea
Radiation therapy or chemotherapy
Using any Lash or Brow Serums
Skin Disorder
Botox
Alopecia
Used drugs or alcohol in past 24 hours
Hemophilia
Have you had any form of Permanent Makeup before?
Yes
No
When did you have it?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about PMU Crew?
Facebook
Instagram
Google
TikTok
Online Ads
Posters/Banners
Referral
Other
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I consent
I understand that this procedure cannot guarantee 100% expected results.
I consent to and release my rights to any and all photographs and videos that are taken during the service for however the service provider sees fit.
I certify that I am over the age of 18
I release Allyssa and therefore PMU Crew of any liabilities or results related to the treatment.
I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.
I understand that permanent cosmetics are a form of tattooing.
I understand the risks involved and consent to having this procedure done. Risks such as the risk of fainting, vomiting, and infection including bacterial endocarditis for patrons with a heart condition.
I understand that I might experience infection, minor bleeding, swelling, and redness.
I confirm that I have read, understand, and answered this form accurately to the best of my knowledge.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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