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: *

Health Information

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for PMU and must be disclosed and discussed with the specialist prior to treatment.

Please check all that apply and give details below:

Liver disease Pregnancy Breastfeeding Compromised skin near brow area Chemotherapy / Radiation Diabetes Type 1 or Type 2 High blood pressure Auto-immune disease Thyroid / Graves’ disease Any medical condition that causes slow healing or a high risk of infection

If you have ticked any of the above contraindications please give details:

Do you have any other medical conditions? *

Please specify: *

Pre Procedure Advice

Please check each box to show your understanding and agreement:

Post Procedure Advice

Please follow these instructions for 10-14 days after the procedure to improve and prolong the results. If you don’t follow these instructions, it could greatly affect your PMU results.

Please check each box to show your understanding and agreement:

Topical Anesthetic Advice

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 PMU, a numbing cream/gel is used. The products are formulated to be perfectly safe and can be purchased over the counter from any pharmacy/chemist. 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 procedure advice and after care for the best results.

Consent

Please check each box to show your understanding and agreement:

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Tap or click on the signature above to sign