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PMU CONSULTATION FORM

Photograph consent
I agree to photographs being taken BEFORE, DURING and AFTER my procedure which will be kept in my case file or used only with my written agreement for promotional purposes
Patch testing for allergies
I have undergone/been offered an allergy test prior to my initial treatment and thereby release the technician from any liability related to any allergic reaction to applied pigments or other product used after the procedure, or at a later date
Titanium Dioxide

Titanium Dioxide is a clear ingredient in our pigments and is not always visible in the skin, even though it may be present.  Some cosmetic lasers will permanently alter the colour of Titanium Dioxide, therefore it is vital that you inform your laser specialist where your micro-pigmentation procedure is.  Your laser specialist will then take steps to ensure any adverse reactions.

Nickel

I understand that there are traces of nickel in some needles and pigments.  This may affect me if I have an allergy to nickel (in this case a patch test is strongly recommended)

I have read and understood this section.
To comply with the Tattooing Act please tick YES or NO in the following 4 boxes
Are you over 18 years of age?
Are you pregnant or breastfeeding?
Are you mentally fit and physically well to have a procedure today?
Are you under the influence of alcohol or illegal drugs?
MEDICAL HISTORY
Do you have any allergies or allergic reactions to any medicine or products (such as latex, plaster, nickel etc)?
Do you have,or are you having any injectables, fillers, chemical peels or using lash growth serums?
Do you have any imminent holiday plans?
Do you have any confirmed keloid scarring?
Do you suffer from epilepsy and have had a seizure in the last 2 years?
Do you suffer from haemophilia?
Do you knowingly have any infectious or autoimmune diseases?
Do you knowingly have Hepatitis A, B, C or HIV?
Do you suffer from shingles, cold sores, fever blisters or skin disorders in the area to be treated?

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Do you have diabetes?
Do you have any respiratory problems?

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Do you suffer from, or have any problems with wounds healing, excessive bleeding or bruising in the past?
Do you take blood thinners or anti inflammatories?
Do you take Antabuse?
Do you take skin thinning medications such as steroids, cortisones, Roaccutane or have taken it in the last 6 months?
Do you have any significant family history or medical problems that could affect your treatment?
Do you smoke or regularly drink alcohol? Please note if ‘YES’ this may affect your healing process time.
Do you have high or low blood pressure?
Do you wear contact lenses, suffer from glaucoma, blepharitis, regular styles or ever had a detached retina?
Are you currently taking any medication?
Are you 5 weeks pre or post radiotherapy/chemotherapy treatment?
Have you or any other family member ever had a reaction to any local anaesthetics?
Are you awaiting any results from a medical investigation?

IF YOU ANSWERED ‘YES’ TO ANY QUESTIONS:

 

  • I understand my condition or medication may affect the treatment including bruising, bleeding and additional healing time.

  • I understand the importance of providing accurate and complete medical history and that withholding any medications or medical conditions may be detrimental to my health and the outcome of the procedure.

If there are any changes to my medical history, I understand that I am responsible for informing my technician.

PRIVACY STATEMENT

The information provided is required for insurance purposes and to ensure that I have recorded all elements of the treatment you are about to have, including any medications or medical conditions that may affect your treatment.

The information will only be used as a record of your treatment and will be kept in a secure location.  This information will not be shared with any third party for marketing purposes.  I will, however, use it to contact you for further appointments unless expressly requested otherwise.  You are entitled to request a copy of the information on this form at any time.

  • I have read and understand how my data will be used.

  • I am aware that I can access this data at any time by request.

  • I understand that my data will not be shared with a third party.

I agree to all of the things detailed in this form and confirm that all the informtation is correct to the best of your knowledge. I agree to use my written name and acceptance below as my electronic signature.

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