PMU Consultation/Consent Form | Aesthetics Forms Portal

PMU Consultation and Consent Form

Covid-19 Screening

To ensure the safety of all parties and to stop the further spread of the Covid-19 virus, please complete the below questions as honestly and accurately as possible prior to your appointment date.

1. Have you, or anyone in your household, had Covid-19 in the last 14 days? *

Please give details: *

2. Are you, or anyone in your household, awaiting test results for Covid-19? *

Please give details: *

3. Have you, or anyone in your household, had any of the following symptoms in the last 14 days: Continuous cough, Fever, High temperature, Loss of sense of taste, Loss of sense of smell? *

Please give details: *

4. Have you, or anyone in your household, been in contact with anyone with confirmed Covid-19 in the last 14 days? *

Please give details: *

5. Have you, or anyone in your household, travelled outside the US in the past 14 days? *

Please give details: *

6. Have you received a Covid-19 vaccine? *

Which vaccine did you receive? *

Have you received one or two doses? *

When did you receive the first dose? *

When did you receive the second dose? *

Appointment Guidance

If you have answered yes to any of the above questions we will be in contact as you may need to reschedule your appointment with us.
Please only attend at your appointment time.
Please ensure you are on time - if you are late this may result in your appointment being cancelled.
Please attend your appointment unaccompanied.
Please limit the personal possessions you bring with you.
Please wear a face mask/covering to your appointment.
Upon arrival please wait until you are called forward to reception.
Upon arrival please use the hand sanitiser provided.
Please maintain social distancing where possible.
If you experience Covid-19 symptoms after your appointment please contact us immediately.

Please tick each statement to show your understanding and agreement. *

I’m willing to get my body temperature checked before beginning my salon/clinic services. If my temperature is above 37 degrees celsius I agree to not visit the salon/clinic for the next 14 days I agree not to visit the salon/clinic for any of the services provided if I have the symptoms of Covid-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below I confirm that I understand and agree to all terms and statements in this form.

Client Signature: *

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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

PMU procedure normally requires multiple treatment sessions. For best results clients will be required to return for at least one retouch appointment. This will take place 4 -6 weeks after the initial procedure. Those with oily skin may require an additional touch up. Please be aware that color intensity will be significantly darker and sharper immediately and a few days after the initial procedure but the color will reduce by 30-50%.
Although numbing cream is used during the procedure sensitivity or discomfort may still be felt. Skin may be red and/or swollen after the procedure.
Please wear your normal make up on the day of your procedure.
Please DO NOT drink alcohol 24 hours prior to the treatment.
Where possible, try to avoid the following herbs and spices prior to your appointment: Black pepper, Cardamom, Any member of the Zingiberaceae (Ginger) family, Cayenne, Cinnamon, Garlic, Horseradish, Mustard.
Please DO NOT shape or wax your brows before the procedure. Your technician will shape brows during the procedure.
Botox AHA products and retinoids should be avoided for 2 weeks prior to the procedure.
Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure.
Chemical and laser peels should be avoided no less than 6 weeks prior to procedure.
Patients prone to cold sores/fever blisters should take an antiviral prior to treatment.
Hormone therapies can affect pigmentation and/or cause sensitivity.

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.

Avoid getting anything on the brows including water except for cleansing as directed. You may blot for the first few hours with sterile gauze to remove any excess fluids if necessary.
Cleansing: In 2-3 hours wash lightly with slightly damp Q-tips and antibacterial or green soap (non-scented orange Dial soap is a great option). Repeat this very gently during days 1-4. When washing it should be very gentle and with hardly any water. Do not attempt to remove the barrier film if it was applied. Allow it to come off naturally in its own time. Please avoid saturating brows with water. After the initial 3 days of washing you may very sparingly apply balm to hydrate your brow area for dryness relief.
Do not pick scratch or rub the brows. The flakes must fall off on their own or you will risk removing the color and possibly scarring. You may tap them to alleviate any itch.
Do not soak the treated area in the bath pool or hot tub. For 30 days refrain from swimming in salt water or chlorinated pools saunas hot yoga steam rooms or sun beds.
No exercise for 14 days. After 14 days – when exercising wear a sweatband to avoid sweat on brow area.
Do not expose treated area to direct sunlight. After healed (30 days) use a sunscreen to avoid fading from the sun.
No makeup should be applied directly on the brows during the healing process.
If your eyebrows get wet during the healing process pat them dry with a towel DO NOT RUB.
Avoid using daily skincare products directly on the eyebrows.
If you are planning a chemical peel or any other medical procedure please inform therapist of the procedure you have had. Procedure should only be done once the healing process is complete.
If you are due to give blood after the procedure please inform your nurse about the PMU treatment you have had as this might alter the results.

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