PMU Consultation/Consent Form | Aesthetics Forms Portal

PMU Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical Information

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Do you have any medical conditions? *

Please specify: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Medical Contraindications: Do any of the following apply to you? Please tick all that apply.

Skin Contraindications: Do any of the following apply to you? Please tick all that apply.

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

Service: *

Microblading Lip Blushing Eyeliner Scar Camouflage Blush Other

Have you had Microblading or other Permanent Makeup before? *

When did you last have Microblading / Permanent Makeup done? *

Did you have any problems with healing afterwards? *

Please specify: *

Do you wear contact lenses? *

Do you have any implants? *

Do you have any Botox or other injectables? *

Do you participate in outdoor recreational activities? *

Pre-Treatment Advice

Please wear your normal make up on the day of your treatment.
Please DO NOT drink alcohol in the 24 hour period prior to the treatment - Alcohol thins your blood and could result in excess bleeding, as well as compromise the overall quality and outcome of the treatment.
Where possible, try to avoid the following herbs and spices in the 48 hour period prior to your appointment: Black pepper, Cardamom, Any member of the Zingiberaceae (Ginger) family, Cayenne, Cinnamon, Garlic, Horseradish and Mustard - This is for the same reason as alcohol, as these can thin your blood too.
Please DO NOT shape or wax your eyebrows beforehand - Your technician will shape your eyebrows during the treatment.
Botox, AHA products, Retinoids and Laser treatments should be avoided for at least 2 weeks prior to the treatment.
Exfoliating treatments such as Microdermabrasion should not be performed within 2 weeks prior to treatment.
Chemical and laser peels should be avoided no less than 6 weeks prior to treatment.
Patients prone to cold sores/fever blisters should take an antiviral prior to treatment.
Hormone therapies can affect pigmentation and/or cause sensitivity - Please discuss with your therapist if you are using hormone therapies.

Please tick the box to confirm: *

I have read and understood the pre-treatment advice.

How long will PMU last?

Once applied, permanent makeup pigment does fade. How long your permanent makeup results last will depend on your skin type, lifestyle, and how often you get touch-ups.

The effects of permanent makeup last anywhere between 18 and 30 months. Once pigment from the procedure begins to noticeably fade, you’ll need to come back for a touch-up application. Touch-ups can be necessary every six months or every year, depending on your skin type and preferred look.

Permanent makeup touch-ups are similar to getting root touch-ups for your hair. If you go when your permanent makeup first starts fading, you can simply have the color filled in. But if you wait longer than recommended, you may have to have the whole permanent makeup procedure done over again.

If you have oily skin, you’re still a candidate for permanent makeup. But the results might not last as long as they would on other skin types. High amounts of sebum, or oil, being secreted from your skin can make it more difficult for pigment to adhere and stay in your skin. Speak to your therapist about any concerns you have about your skin type and how long you can expect your results to last.

Potential Side Effects and Risks

Allergic reactions can occur from any anesthetics used during the procedure - If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.

Numbness – We cannot accept responsibility if the area to be treated does not respond to the numbing cream. Each individual is different according to skin type. Some clients report the area to be completely numb, while others may experience some discomfort.

Procedure – For the permanent makeup treatment, a numbing cream/gel is used. The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness/swelling that can last 1-4 days. You should always follow your post-treatment advice and aftercare for the best results.

Aftercare Advice

Please read carefully.

Follow the AWM aftercare advice - Absorb, Wash, Moisturize.

Absorb (Day of treatment)
- After the procedure, gently blot the area with a clean tissue to absorb excess lymph fluid.
- Do this every 5 minutes until the oozing has stopped.
- Removing this fluid prevents hardening of the lymphatic fluids.
Wash (Days 1-7)
- Wash daily to remove bacteria, build up of product and oils, and dead skin. (Don't worry, THIS DOES NOT REMOVE THE PIGMENT!)
- Gently wash the area each morning and night with water and gentle soap or an unscented cleanser like Dial Soap, Cetaphil, or baby shampoo. With a very light touch, use your fingertips to gently cleanse the area.
- Rub the area in a smooth motion for 10 seconds and rinse with water ensuring that all soap is rinsed away.
- To dry, gently pat with a clean tissue. DO NOT use any cleansing products containing acids (glycolic, lactic, or AHA), or exfoliants.
Moisturize and hydrate (Days 1-7)
- Apply a tiny, rice grain amount of the recommended ointment/solution 3 times a day with a cotton swab and spread it across the treated area.
- Be sure not to over-apply, as this will suffocate your skin and delay healing. The product should be barely noticeable on the skin.
- NEVER put the product on a wet or damp tattoo.

Important Reminders:

Use a fresh pillowcase while you sleep.
DO NOT rub, pick, or scratch the treated area. Let any scabbing or dry skin naturally exfoliate away. Picking can cause scarring or loss of color.
No facials, botox, chemical treatments or microdermabrasion for 4 weeks.
Avoid hot, sweaty exercise for one week.
Avoid direct sun exposure or tanning for 4 weeks after the procedure. Wear a hat when outdoors.
Avoid sleeping on your face for the first 10 days.
Avoid face-down swimming, lakes, and hot tubs for the first 10 days,
Avoid topical makeup and sunscreen on the area.
Avoid long, hot showers for the first 10 days. Limit your showers to 5 minutes so that you do not create too much steam. Keep your face/procedure area out of the water while you wash your body, then, at the end of your shower, wash your hair. Your face should only be getting wet only at the end of the shower. Avoid excessive rinsing and hot water on the treated area.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I accept that any treatment I am going to receive is at my own risk.

I certify that I have read, fully understood, and completed this form to the best of my knowledge.

I understand that failure to disclose information requested above may result in adverse side effect(s), unknown because of this to which I accept full liability/responsibility.

The treatment(s) and possible side effect(s) have been fully explained to me.

I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request.

I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during, or immediately following, the treatment.

I fully understand the above and consent to the Permanent Makeup (PMU) treatment(s) to be carried out.

Client Signature: *

Tap or click on the signature above to sign