PMU Consent Form

PLEASE READ AND SIGN

Forms provided are intended to be a guide for new students and a business attorney should review the forms as they pertain to their specific state, business practices, and service offerings to comply with local and state laws and or guidelines.

First Name

Last name

Phone

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I am over the age of eighteen, am not under the influence of drugs or alcohol, and am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.

Initial

Patch Test Option: I understand a patch test of the pigment to be used can be requested and performed by my medical professional on my own and at my request (see options below). YOUR COMPANY’S NAME patch tests are not performed to diagnose or to foresee an allergy but only to see how the skin takes to tattooing and potential color hue. A fee of not less than $XX applies in which I am responsible. A non-reactive patch test does not preclude an allergic reaction occurring at a future point in time.

I decline a color patch test
I request a color patch test ($XX) X# of weeks prior to my procedure.
Additional Consent:

I have been informed of the nature, risks and possible complications and consequences of permanent 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, inconsistent color, spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fading or loss of pigment may occur. Although the skin of the tattoo procedure site is cleaned with an anti-microbial cleanser, it is not likely all bacteria will be killed. Deeper layers of skin inhabit micro-flora bacteria. Infection can result from resident micro-flora bacteria not removed even with the use of a thorough skin cleansing. Infections can be acquired anytime the skin is broken. The tattoo process in general leaves the skin barrier open for days and the recipient vulnerable to infection.

Initial

I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), or scarring is a possibility as result of my body’s reaction to the skin being broken during the procedure. I realize that my body is unique and YOUR COMPANY’S NAME cannot predict how my skin may react as a result of this procedure.

Initial

I acknowledge the receipt of written instructions advising me of the proper care of my procedures and I recognize the absolute necessity for following these instructions. I understand that my failure to do so may jeopardize my chances for an optimal outcome.

Initial

I understand that if I have any skin care 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 the potential adverse changes may not be correctable. If permanent cosmetics present possible complications to my existing cosmetic enhancements, treatments, or surgeries I will consult with a physician and obtain medical clearance. If I choose to move forward with permanent cosmetics without obtaining medical clearance, I assume the responsibility and consequences. I understand that future laser treatments or other skin altering procedures, such as plastic surgery, implants and injections may alter and degrade my Permanent Makeup. I further understand that such changes are not the responsibility of YOUR COMPANY’S NAME. I further understand that such changes in my appearance may not be correctable through further permanent makeup procedures.

Initial

If I am on any medication for depression or any other mood-altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctors’ instructions before contemplating any permanent cosmetic procedure around my lips. I understand I will be referred to my physician to obtain an anti-viral medication in order to have my lips tattooed. If I am unable to obtain an anti-viral, I will notify YOUR COMPANY’S NAME. I understand that this is a cosmetic procedure and not to treat a health condition. It is my responsibility to obtain advice by a medical professional for my best interest if I have any medical related concerns. I release YOUR COMPANY’S NAME and its technicians and affiliates of all liability for this self-elected procedure.

Initial

I understand that tattoos may cause MRI (Magnetic Resonance Imaging) artifacts and that there may be a warming and/or tingling sensation in the permanent cosmetic procedural area during the MRI due to the iron oxide properties of some pigments. It is understood that I will notify my Radiologist, Physician, and/or Technician of having permanent cosmetics. Ice packs can regulate the temperature of the skin during an MRI procedure.

Initial

For documentation for the file and comparison, the taking of before, during and/or after photographs of my procedure(s) are required for record purposes and for use in presentation portfolios and is a condition of said procedures

Initial

I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. I am aware that cosmetic tattooing is not an exact science, but an art and I acknowledge that no guarantees have been made to me as to the results of the procedure. YOUR COMPANY’S NAME does not guarantee the success of removal and or corrective procedures due to the substantial number of variables that affect the success of such procedures. Client acknowledges counsel by a representative of YOUR COMPANY’S NAME as to the probability of success of such procedures. I have read and understand the contents of each paragraph above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of, the procedure(s).

Initial

Aftercare products must be approved by YOUR COMPANY’S NAME. If you have allergies to any specific ingredients, please notify your technician so he / she can suggest an approved alternative. Sharing aftercare products is not allowed as it can result in cross-contamination.

Initial

All my questions have been answered to my satisfaction, I have enough information on which to base an informed consent to the self-elected procedure(s) described in my price quote. I accept full responsibility for the decision to have this cosmetic tattoo application procedure.

Initial

I understand that my Artist will draw an eyebrow, lip or eyeliner design in order for me to have an idea of what my tattoo will look like (exception: eyeliner variations without a wing / upturn). The drawing is a template for the shape, size and contour of the tattoo. I understand perfect symmetry is not an option considering faces in general are not symmetric, including my own. I understand my artist will aim to achieve the best outcome in symmetry within 80%. I will be asked to approve my design with a "thumbs up" hand gesture while having my photo taken to document my approval of the drawn design. If I am not comfortable with the design, I will notify my artist. If I need more time than what is allotted, I understand I will need to schedule an additional time block (cost of $XXX).

Initial

If my artist gets a needle stick injury with my used needle, I agree to accompany the artist to the emergency room. I further agree to medical testing at my own expense and release of those records to YOUR COMPANY’S NAME and the artist that performed my procedure.

Initial

I agree to the above statements by signing my name below:

Signature

Please Enter Your Minor’s Information

Name Of Minor

First Name

Last name

Name Of Guardian

First Name

Last name

Signature Of Guardian

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