PMU CLIENT INTAKE FORMS

CLIENT INTAKE FORMS

Read and fill out this form completely, making certain that you understand everything and print your contact information clearly. Please review Brow Policies and Brow FAQs before submitted intake form via the website: www.TouchedbyTe.com .
Name:*
First Name
Name:*
Last Name
Email:*
example@example.com
Requested/Appointment Date:*

MonthDayYear
Requested Date or Date of Service
Requested/Appointment Time*

:HourMinutesAM/PM Option
Phone:*
(XXX) XXX-XXXX
Instagram tag: @
Physical Address:*
DOB*

MonthDayYear
Date
Age:*
DL or ID#*
Upload photo of unexpired DL/ID*

Browse Files
Under Louisiana Law, it is a requirement all persons being serviced be above the age of 18 and supply federal or state issued identification. Please upload your identification here. Cancelof
Upload picture of your brows*

Browse Files
Take a picture with no makeup in natural lighting with no filters Cancelof
Upload picture of your lips

Browse Files
Take a picture with no makeup in natural lighting with no filters Cancelof
Upload picture of your eyeliner

Browse Files
Take a picture with no makeup in natural lighting with no filters Cancelof
Upload Doctors Approval Note

Browse Files
For clients with preexisting conditions such as diabetes, skin disorders, cancer, etc. Cancelof
What procedure(s) are you interested in having? *
Ombre/Combo Brow, Microblading, Brow Correction, Eyeliner, Lip Blush, Lip Neutralization, Beauty Mark(s)
How did you hear about Touched by Te’? *
Friend/Referral, IG, FB, TBT website, Google, Other
Have you previously had permanent makeup services?*
List all services if applicable or N/A.
I give permission to “Touched by Té to show my before and after brow photos and/or videos to other potential clients (e.g. Facebook, Instagram, website, etc Please mark:*

YesNo
Client's Signature*

Clear
Date*

MonthDayYear
Date

INFORMED CONSENT & RELEASE FORM
You have the right to be informed so that you can make the decision whether to undergo the procedure(s) after knowing the risks and hazards involved. This disclosure is not meant to frighten you, it is simply an effort to make you better informed, so you may give, or withhold, your consent to the procedure. If you decide not to go forward with the procedure, please understand that all appointment retaining fees and or deposits are nonrefundable. Please read the statements below and write your initials before each one, to indicate you understand them completely. As a client, it is your responsibility to inform your brow tech of all possible concerns before she begins your procedure.
I understand that semi-permanent makeup is a form of tattooing and requires implantation of pigments into my skin using a needle.*
I understand there is a possibility of discomfort and pain during this procedure.*
This type of tattooing is considered semi-permanent, it will fade with time and therefore requires touch ups. Results can vary and are dependent on clients care and skin type. No guarantee has been made on tattoo longevity.*
I have been informed that I should lose any significant areas of color during my healing process that I understand it 10-15 days for color to appear back fully. If the color does not return within that time frame I should return for a touch up in 6 to 8 weeks after the procedure to achieve the best results.*
I have been informed that my results depend on my natural skin regeneration and or skin type. Often, even with proper care, customers can develop light spots or lose original hair strokes which can make the brow look uneven. This is normal because of natural skin regeneration and is not a process any eyebrow technician can control. Skin type and excessively oily skin, larger pores and thicker skin can affect the absorption of pigment. In this case, one or more touch ups will be needed to achieve optimum results.*
I understand there may be risks and hazards related to the performance of this procedure, including but not limited to: reaction to the pigment and/or other products that will be used, light headedness, bleeding, bruising, swelling, scarring. *
I understand that it is my responsibility to advise my brow tech of any problems that I (or my doctor) think could occur for any reason (including but not limited to: allergies, illnesses, medications- including aspirin and/or other medications that cause the blood to thin) and I understand that my brow tech may elect to delay or not go forward with the procedure based on this information.*
I understand if I cancel my appointment or my brow tech finds that I have any condition that would interfere with the the service, then the pre scheduled appointment will be automatically cancelled and I will still have to pay for the service time.*
No warranty or guarantee has been made to me because of this permanent makeup/camouflage/correction procedure, although my brow tech will do their best to make sure I am happy with the results, the final result cannot be guaranteed.*
I understand that my brow tech will do their best to insure the most possible symmetry of my brows. However, be not every person's face has complete symmetry no promises can be made on the symmetry of my brows.*
I have received a written copy of aftercare instructions for the tattooed area and they have been fully explained to me.*
I understand that if I have any issues with my service, I will forward my complaints solely to my brow tech, Chaunte at Touched by Te' Makeup Artistry. *
Client's Signature*

Clear
Date*

MonthDayYear
Date
I certify that this Informed Consent, Medical History and Release Agreement was completed by me and all entries in it and information are true and complete to the best of my knowledge. I also certify that I have been fully informed of the risks of tattooing/ permanent makeup application, including but not limited to: infection, scarring, difficulties in detecting melanoma, and allergic reactions to permanent makeup/ tattoo pigment, latex gloves, and other products used. Having been informed of the potential risks associated with getting the permanent makeup/tattoo, I still wish to proceed with the application and I assume all risks that may arise from the procedure. I also certify that I take full responsibility and waive any claims against Touched by Te’ Makeup Artistry to the fullest extent permitted by law from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or as signs may have for personal injury or otherwise, including and direct and/or consequential damages, which result or arise from the application/implantation of permanent makeup pigment for eyeliner, eyebrows, lips, re-coloration, camouflage or otherwise, whether caused by the negligence or fault by my brow artist. I fully understand the questions, terms, and conditions of this Informed Consent, Medical History and Release Agreement, and all questions have been answered for me. *
Print Name
Signature*

Clear
Date*

MonthDayYear
Date
I have read "A Guide to Achieving Your Perfect Brows", BROW FAQ’s, and BROW Policies and understand that my retainer + processing fee invoice will be sent to me via email and is non-refundable and non-transferable once my appointment has been confirmed. Payment should not be made until appointment is confirmed.

Yes

Retainer + Processing Fee

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Total

$0.00

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CLIENT INTAKE FORMS

CONFIDENTIAL MEDICAL HISTORY FORM

INFORMED CONSENT & RELEASE FORM

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