• Bloom PMU Consent Form

    Bloom Lash & Brow
  • Date of birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you pregnant or breastfeeding?*
  • Have you had any botox or fillers in the last 30 days?*
  • Have you recently had any brow/lash tinting?*
  • Do you get keloid scars?*
  • Do you have any type of irritation of the skin such as blemishes, rashes, psoriasis, eczema, rosacea, and sunburn on the area of the cosmetic procedure?*
  • Have you been on Accutane within the last year?*
  • Are you using any AHA’s (Alpha Hydroxy Acid), Retin-A or Retinols in the last 30 days?*
  • Are you using or have you had any, chemical peels, or laser treatments on the face in the last 30 days?*
  • Are you Diabetic or taking any blood thinning medications?*
  • History of cancer and/or cancer treatments?*
  • Do you have AIDS/HIV, Hepatitis or any other viral infections and/or diseases?*
  • Do you have any autoimmune disorders?*
  • History of difficulty with topical numbing?*
  • Are you currently going through any hormone therapy?*
  • History of allergies or adverse reactions to makeup, pigments, latex, disinfectants, metals or other sensitivities related to body art procedures?*
  • History of epilepsy, seizures, fainting or narcolepsy?*
  • Difficulty numbing with dental work?*
  • Allergic Reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, etc.?*
  • Oily Skin?*

  • I have read and completed this consent form truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from cosmetic services received. The services I receive are voluntary and I release the company and/or service professional from all liability. 

    • I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated procedure. The general nature of Powderbrows, has been explained to me. 
    • If an unforeseen condition arises in the course of the procedure, I authorize my technician to use her professional judgement to decide what she feels is necessary under the given circumstances. 
    • I accept the responsibility for determining the color, shape and position of the procedure as agreed during consultation. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may start fading over a period of 10-12 months. Even once the color fades, pigment itself may stay in the skin indefinitely. 
    • I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers 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 desired results and that 100% success cannot be guaranteed during the first session. I understand that I may have to return for a repeated procedure at my own expense. 
    • I acknowledge that complications are always possible as results of the permanent makeup procedure, especially in the event that post-procedural instructions are not followed.
    • I realize that my body is unique and the practitioner cannot predict how my skin may react as a result of the procedure.
    • Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-5 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed. 
    • I have been advised that the true color will be seen 4 weeks after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given. 
    • I understand that if I do not abide by strict aftercare, I can ruin may results. The aftercare is crucial for optimum pigment retention. 
    • I acknowledge that no guarantees have been made to me concerning the results of this procedure.
    • When you leave the salon, your ebrows are intact. How your body heals them is out of the control of the technician. This is 100% your body's job. Even when following the aftercare, fading, blurring or poor retention can still happen depending on your skin type and lifestyle.
    • I can confirm that I have recieved a copy of aftercare details.
    • I understand that NO refunds after service will be performed. 
    • Rachel Camille Collins can release me at anytime from any future services if she feels policies or procedures are not followed. 
    • 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 it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsisten color, and spreading, fanning or fading of pigments.
    • I acknowledge that I have recieved a copy of the Discolsure Statement and Notice for Filing Complaints, recieved a copy of the Aftercare Information Shett, and completed the Client Health Questionnaire and recieved any additional, applicable information.
    • In addition, this record serves as a signed documentation that the body art facility performing your tatto, piercing, and/or branding is a licensed facility by the State of Michigan. It is recommended the individuals or organizations visit www.michigan.gov/bodyart to determine the current license status of the body art facility before proceeding with any body art procedure. 

  • I request the permanent makeup procedure and accept the permanence of this procedure as as the possible complications and consequences of the said procedure (initials).
    I certify that I have read the above paragraphs and have explained to my understanding the consent and procedure permit. I accept fully responsibility for the decision to have this cosmetic procedure work done. I give Rachel Camille Collins permission to perform the Powderbrows procedure on me.

    ***SEEK MEDICAL ATTENTION: IN CASE OF ABNORMAL INFECTION OR SWELLING, PLEASE SEEK MEDICAL HELP FROM YOUR DOCTOR, YOU HEALTH AND WELL-BEING ARE OF UTMOST IMPORTANCE***

  • Date of Service*
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