Consent acknowledgements "*" indicates required fields 1Client information2Informed consent acknowledgements3Confidential medical history4Signature and Legal Name Full Name*Phone*Email* Address*Age*Date of Birth* MM slash DD slash YYYY Procedure(s) being performed todayHow did you hear about usThis field is hidden when viewing the formAppointment metadataThis field is hidden when viewing the formAppointment IDThis field is hidden when viewing the formService NameThis field is hidden when viewing the formEmployee NameThis field is hidden when viewing the formAppointment DateThis field is hidden when viewing the formAppointment Start Time PMU is a form of tattoo requiring implantation into the skin using a needle or blade* I understand and agree.I am the person on the ID presented and I am at least 18* I understand and agree.I am not under the influence of alcohol drugs or other substances* I understand and agree.I am not pregnant or breastfeeding* I understand and agree.All questions about the procedure(s) have been answered to my satisfaction* I understand and agree.I received aftercare instructions and agree to follow them* I understand and agree.I understand risks and hazards including allergic reaction lightheadedness bleeding bruising swelling scarring infection* I understand and agree.I have been advised of products used and offered a patch test* I understand and agree.Patch test selection* I request a patch test prior to the procedure I decline a patch test and wish to proceed FDA pigment statement acknowledgement* I understand pigments are approved by the FDA and health consequences are unknownFDA pigment statement acknowledgement* I fully understand this consent medical history and release and all questions were answered*Other informationAny other information you should provide to your technician* yes no If yes please explainResponsibility to disclose issues and technician may delay or decline procedure* I understand and agree.Skin treatments or surgery may cause adverse changes* I understand and agree.No warranty or guarantee and results depend on following aftercare* I understand and agree.Opportunity to ask questions about procedure risks and hazards* I understand and agree.Permission to use my images for work training advertisement* I understand and agree.Cancellation policy acknowledgementCancellation policy acknowledgement* late cancellation less than 48 hours or no show results in a 75 missed appointment feeTouch up timing policy acknowledgement* follow up touch up eyebrows only not performed within 5 to 8 weeks becomes yearly touch up and charged accordingly Ate within last 4 hours* Yes No Any medication that might affect healing or the procedure* Yes No Botox Dysport or fillers in last 2 weeks* Yes No If yes list all medicationsAllergic to latex* Yes No Not sure List all other allergies including antibioticsmedical history (please check yes or no)Diabetes Yes No Heart disease / heart condition Yes No High blood pressure Yes No Epilepsy / seizures Yes No Autoimmune disease Yes No Thyroid disorder Yes No Blood clotting disorder Yes No Keloid or hypertrophic scarring Yes No Anemia Yes No Skin conditions (eczema, psoriasis, dermatitis) Yes No Herpes / cold sores (especially for lips) Yes No Cancer or chemotherapy (past or present) Yes No Hepatitis or HIV Yes No Check any conditions that apply* Diabetes Epilepsy Asthma Fainting Nursing or breastfeeding TB Eczema or psoriasis Other skin conditions None List all other issues or illnesses Legal name for certification*Signed date* MM slash DD slash YYYY upload ID or driver license*Max. file size: 20 MB. Signature*CAPTCHA
