PMU Medical and Consent

Full Name*

First Last

E-mail*

We will never SPAM or sell email addresses to third parties.

Phone:*

ex. 555-555-5555

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthdate:*

ex. 01/05/1960

Age:*

Which pronouns do you prefer?

She/HerHe/HimThey/ThemOther

Who referred you to Fine Line Studio?

What is your Instagram name?

Which service are you scheduled for?

Do you have any permanent cosmetics or tattoos on the areas being treated?*

NOYES

Are you allergic to anything?*

NOYES

If yes, please list allergies:

What is your skin type?

DryCombinationOily

Have you had any of these health conditions in the past or present? (Please mention dates)

Do you follow a regular exercise program?*

NOYES

Are you currently a tobacco smoker?*

NOYES

Have you had Botox or fillers within the last 7-14 days?*

YESNO

After your treatment you will need to avoid working out, heavy sweating, steam rooms and/or saunas for 7-10 days.

Smoking greatly reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your treatment.

Do you currently use any of the following?

Do you have sensitive skin?

I understand that I must discontinue use of ALL of the above 7 days prior to treatment. Accutane or Roaccutane must be discontinued 1 year prior to treatment.*

YES, I will discontinue.

Do you currently have any rash, windburn, sensitivites or other issues on the area being treated? If you have any of these conditions you will need to allow your skin to heal properly for 4 weeks prior to your treatment.*

NOYES

If yes, please explain:

Please list any Vitamins or Medications you are taking; Antibiotics included:

Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

NOHyper-pigmentHypo-pigment

Have you used an acne medication? *

NOYES

If yes, please list medication:

Please explain the details:

Have you ever had an ALLERGIC reaction to any of the following?

Female Clients

Are you pregnant or trying to become pregnant?

NOYES

Are you lactating?

NOYES

Preparing for your appointment

• You will shape your eyebrows prior to your appointment if you have a specific shape preference. If you are unsure, or wanting to possibly change your existing shape, you may grow them out and they will be groomed during your appointment. If you wish to wax or thread them, please do so at least 5 days before your appointment.

• It is required that you have no sun/tanning bed exposure for 30 days before and after your procedure. Please account for both your initial and follow up appointments if you have a vacation planned where you will be getting sun.

• You will not be able to exercise the day of or 7 days after your appointment. This includes any and all activities that produce sweat.

• Please do not take blood thinners for 24 hours before your appointment. This includes aspirin, niacin, vitamin E, fish oil, alcohol, and caffeine, unless advised by a physician.

• Do not tint or dye your brows for 5 days before your appointment.

• You must bring current photo identification with you.

Deposits and Studio Rules

• A 50% NONREFUNDABLE deposit is required to book. Your deposit will go toward your appointment.

•There is a 48 hour reschedule policy, and a 15 minute late policy. If you reschedule prior to 48 hours, your deposit will transfer to your next appointment (1 time only). If you are 15 minutes late you run the risk of losing your appointment slot as well as your deposit. If you are late for a touch up appointment, you will have to place a new deposit for the rescheduled appointment.

• The studio accepts cash or major credit cards.

• Small children are not allowed in the room during the procedure. There is a waiting room, as well as one seat available in the work space for 1 guest. The appointment will typically take 2-3 hours, so please keep this in mind when inviting guests.

Aftercare Rules

I prefer a dry heal for your fresh brows/freckles. Dry healing consists of keeping the surface clean, and avoiding scabbing. The day of your appointment, and the second day you will be required to use clean hands and a lightly dampened cotton round to wipe away lymph from your brows every 2-3 hours. On the third day you may use 1 drop of grapeseed oil to moisturize your brows. You do not want your brows to feel greasy or have any visible residue. The area must remain dry for 7 days. Do not get your brows wet in the shower. Do not exercise, swim, sunbathe, or sauna for 7-14 days. Sweat and moisture will cause the pigment to fade while healing. Do not tan or expose your brows to direct sunlight for 4 weeks. Do not use any skincare products on your eyebrows for 6 weeks. Do not pick, scratch or touch your eyebrows. Do not apply makeup to your brows for 4-6 weeks. Your perfecting appointment will be scheduled by 6-8 weeks.

I understand, and have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the permanent cosmetics specialist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Fine Line Studio and/or the skin care professional from liability and assume full responsibility thereof.*

I understand the cancellation policy.

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with its known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, the pigment may be modified slightly due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent cosmetics procedure and accept the permanence of the procedure as well as the possible complications and consequences of the procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each individual's reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases pigment is permanent*

Your Initials Here

I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.*

Your Initials Here

I have received pre and post procedure instructions and will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescriptions, I will advise my technician.*

Your Initials Here

I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness, and bruising may occur.*

Your Initials Here

I understand that successful color saturations cannot be guaranteed due to hidden scar tissue and previous permanent makeup or laser treatments.*

Your Initials Here

I understand that implanted pigment color can slightly change or fade overtime due to circumstances beyond your control, and will need to maintain the color with future applications*

Your Initials Here

I accept the responsibility to explain to you the specific color, shape, and position for any procedure done today prior to starting the procedure.*

Your Initials Here

I acknowledge that the purposed procedure involves risks inherit in the procedure, and have possibilities of complications during and/or following the procedure such as infection, misplaced pigment, poor color retention, and hyper pigmentation.*

Your Initials Here

I have been advised that a touchup session is highly recommended to make any adjustments to shape, color, and to fill pigment that may have poor retention or uneven pigmentation due to poor healing. *

Your Initials Here

I understand that PMU is a semi-permanent cosmetic tattoo application. Although the nano brow technique is effective in the majority of cases, no guarantee can be made that a specific client will benefit from the procedure and results depend on skin texture, oiliness, etc. Therefore, a perfect result is not a realistic expectation. Initially, the color will appear more vibrant, stronger, or darker compare to the end result. Usually within 3-10 days the color will fade 40-50%, soften and look more natural. Additional touchups are likely needed within 8 months to 2 years depending on my skin and how I care for my new eyebrows. *

Your Initials Here

I certify that I have read or have been read the contents of this form. I understand the risk and alternatives involved in this procedure. I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me. I authorize that Jacqueline Rice as my Permanent Cosmetic Artist to perform on my body the procedure that I desire today.*

Your Initials Here

OPTIONAL: I grant permission to use photos of my progress for marketing purposes on www.Motherofblades.com, www.finelinestudiopmu.com or other business listing pages such as Instagram.*

YesNo

Date*

MonthDayYear

Photo of front of ID:*

Photo of back of ID:*

Photo of area being tattooed, without makeup:*

Medical & Skin History