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PMU Consult Form
Micropigmentation
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Personal information
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Name
Street Address
City, State
Zip code
Email
Date of birth
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What procedure are you looking to have done
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Lip Blush
Microblading/ Microshading/ Combo
Please upload a current photo of the brows or lips you would like serviced so we can properly assess the area and assist you accordingly.
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Provide a photo of the style of brows or lips you're hoping for. This way we can go over probability, and options that will best suit you and your desired look!
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Medical History Inquiry
Have you had or currently have any of the following
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Yes
No
Currently Pregnant or breastfeeding
Had undergone Botox treatment
Are you Diabetic
Has Hepatitis A B C
Has a Heart Condition
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, epinephrine 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
Policies, payments and refunds
Please list any allergies or medications you are taking or if you answered yes to any question, please explain in the box or any question you may have prior to procedure.
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If you choose no to any question, you may be disqualified as a client. We need to know you are aware and accept terms and conditions.
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I UNDERSTAND that the deposit is NON REFUNDABLE
I UNDERSTAND deposit will go towards the service agreed on
I UNDERSTAND I will lose any money paid if I fail to cancel or reschedule appointment 24-48hrs I’m advance.
I UNDERSTAND service needs to be paid in full the day of the appointment.
I UNDERSTAND if I’m not happy with the service received and nothing on my behalf was a mistake just that you don’t like it, you won’t get a refund.
I UNDERSTAND I may reschedule no more than 2 times. Any money paid is NON REFUNDABLE
I Agree not to leave a negative review unless I communicated beforehand with the artist
I Will send a before picture to see if I can be serviced on
I UNDERSTAND and agree with all policies and therefore can’t take action against Vicious Binx LLC as I am consenting to services received and agree as this is my personal choice
I am honest about my medical conditions and will get a Doctors approval letter before service begins if needed.
I understand I have to schedule my touch-up appointment within 30-60 days of initial procedure and it is included in the price of procedure.
If I fail to schedule and come in within 60 days of initial procedure I will be have to pay full price for my touch-up session.
Acknowledgement
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Yes
I acknowledge that some changes might not be corrected in case I undergo other laser hair removal, plastic surgery or other procedures.
I understand that photographs taken for comparison of the before and after procedure are part of the said procedure.
I accept full responsibility for the decision to have this PMU procedure done and to come back for a scheduled touch-up 30-60 days after initial procedure.
I hereby authorize Binx Wilson of Vicious Binx LLC to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises in the course of the procedure(s), I further request and authorize Simply my artist Binx Wilson to use its full judgment and do whatever is deemed advisable and necessary in the circumstances without any liability to Vicious Binx LLC.
I understand that semi-permanent and permanent cosmetic enhancement is an advanced form of tattoo
I accept full responsibility for determining the color, shape, and position of the enhancement as mutually agreed upon during the course of my consultation.
I understand that a reasonable effort will be made to avoid unevenness, but some bone structure, facial deformity or birthmarks, or muscle movement does not call for perfect symmetry.
I understand that dyes, inks, and pigments are not approved by the Food and Drug Administration (“FDA”), and the health effects are not known
I 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. I understand that this is why I may need to return for a touch-up procedure or additional touch-ups thereafter.
I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs.
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 to 2 weeks following the infusion process.
I understand that immediately after the procedure, the enhancement may be 40% to 60% darker than the desired result and may take between 4 to 10 days to lighten.
I understand that the true color will be visible approximately 1 month after each application, and that the color may vary according to skin tones, skin type, age, and skin conditions.
I acknowledge that some skins accept color more readily than others, and no guarantee of an exact effect or color can be given.
I acknowledge that the proposed procedure(s) involve inherent and unforeseeable risks in the procedure and have possibilities of complications during and/or following the procedure(s) such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
I understand that there are few effective methods for pigment removal. Laser removal has proven successful, however is a process, which may take some time.
I have been quoted the cost of today’s procedure and understand that future touch-up rates and/or policies are subject to change.
I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner, employee, or contractor of Vicious Binx LLC. I understand that infection and possible scarring can occur if I do not adhere to the said instructions.
I understand that Vicious Binx LLC can release me as a client at any given time with or without a reason.
I understand that Retin A, Renova, Alpha Hydroxy, Glycolic Acids, Aloe, and Vitamin E products must not be used on the treated areas or forehead area during healing.
To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time.
For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s). I give my consent for before and after pictures to be used for marketing.
I that this cosmetic procedure is not fully permanent and might result to fading in time. I have likewise received and will strictly adhere to procedural instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my responsibility.
I have been advised to do a patch test to identify any allergic reaction to any medicine or anesthetics. Should I waive for the test, I release the technician from liability if I develop an allergic reaction to any of the procedure
I have been informed of the possible risks and consequences of microblading and or micropigmentation and I understand that there might be complications and consequences associated with this procedure, such as: infection, scarring, etc
By signing this document you are claiming that all answers and information you have provided are true, and have a complete, full understanding and acceptance of services that will be provided by Vicious Binx LLC.
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