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PMU Consent Form

Please fill out the following form.

Date of birth
Day
Month
Year

Patient Medical History

Currently Pregnant or Breastfeeding
YES
NO
Blood Disorders / Clotting Issues
YES
NO
Diabetes
YES
NO
Known Allergies (Medications, Latex, Antiseptics)
YES
NO
Autoimmune Diseases
YES
NO
Skin Conditions (Eczema, Psoriasis, Dermatitis)
YES
NO
Seizures
YES
NO
Migraines
YES
NO
Heart Conditions
YES
NO
Asthma
YES
NO
Epilepsy
YES
NO
Current Infection or Illness
YES
NO
High Blood Pressure
YES
NO
Are you currently receiving any medical treatment
YES
NO
Please select the treatment you are coming in for

PMU-Specific History

History of Keloid Scarring
YES
NO
Cold Sores (Lip Blush only)
YES
NO
Skin Conditions near treatment area
YES
NO
Previous PMU Work
YES
NO

PMU Disclaimer

I understand Color retention varies
YES
NO
I understand Results vary and take time
YES
NO
I understand Touch-ups are required
YES
NO
I understand Touch-ups are required
YES
NO
I understand fading over time is expected
YES
NO

Consent Declaration

I Confirm that the Information provided is accurate
YES
NO
I Consent to Images/Videos being taken for Medical Records
YES
NO
I Consent to Anonymized Marketing use of Images/Videos
YES
NO
I Consent to Treatment following Consultation
YES
NO

The clinic shall not be held liable for treatment outcomes or perceived treatment failure where procedures have been carried out appropriately and in accordance with accepted professional practice and aftercare guidance.

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