PMU Sign - Form

Informed Consent, Medical History and Release Agreement

You must read and fill out this form completely, making certain that you understand everything and enter all information clearly.

Full Name:

Email Address:

You have the right to be informed so that you may make the decision whether or not to undergo the procedure(s) after knowing the risks and hazards involved. This disclosure is not meant to frighten you, it is simply in an effort to make you better informed so you may give, or withhold, your consent to the procedure. Please read the statements below and check the box next to each one to indicate that you understand them completely. As a client, it is your responsibility to inform the Technician of all possible concerns before they begin your procedure.

I am at least 18 years of age or am accompanied by a parent or guardian.

I am not under the influence of alcohol or drugs or any other substances, legal or otherwise.

I understand that a lash lift is the process of using a chemical solution to lift and curl the lashes into the desired shape for an extended period of time.

I understand that tinting is the process of applying semi-permanent dye to color, enhance and define the lashes for an extended period of time.

I understand and consent to having my eyes closed and covered for the duration of the service which can vary between 45 minutes to 90 minutes.

I have been informed of the potential risks of this service and have brought forward any questions or concerns (written or verbally) to the attention of the artist before proceeding with this service.

I understand that I am required to answer all questions under the health screening portion prior to my service. My service may be refused if I present with any of the following (including but not limited to): pregnant or nursing, any allergies, current medications, or any other contraindications of this service.

I understand that it is my responsibility to inform my technician of any problems that I (or my doctor) think could occur for any reason (including but not limited to: allergies, illnesses, medications) and I understand that Alyssa’s Beauty Bar may elect to delay or not go forward with the service based on this information.

No guarantee has been made to me about the results, or length of results, of my service as every client’s skin and hair type are different.

I understand that if I wear contacts I must inform my technician and remove them prior to the process.

I understand that results vary depending on skin type, coloring, hair type, amount of hair, etc.

I understand lashes can have a growth pattern such as that of a cowlick, natural curl or slanted. This can cause the lashes to grow in different directions. Although every effort is made to tame or straighten the lashes there is no guarantee the lashes will be perfect as they can take on their own form again.

I agree to the aftercare instructions provided by my technician for the use and care of my permed lashes. I understand that by not following the instructions, the lashes may not stay lifted as long as possible. I have been informed to avoid water/steam, mascara and lash growth serum for 24 hours.

I acknowledge and accept there are possible risks with a Lash Lift & Tint service and although all preventative measures will be taken, injury is possible. I will not hold the artist or business liable for any damages, or injury that may occur as a result of my service.

I have reviewed and understand the contraindications for this service as provided to me.

I understand that although the artist will take all precautions and follow proper application and manufacturer’s instructions; reaction or sensitivity is still possible.

I have received pre and post care instructions and will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful service.

I understand that even though my technician perms the lashes using the proper technique; cleaners, eye gel pads, adhesives, and removers used throughout the service may irritate or cause an allergic reaction.

I understand that there is a chance of under curling, over curling or damage to the natural lashes.

I agree to inform my technician of any eye infections or dry eye that I may be prone to.

I fully understand the questions, terms, and conditions of this Informed Consent, Medical History and Release Agreement, and all questions have been answered for me.

I understand that the taking of before and after photos is part of this process. I also understand that my photos may be used in social media, marketing and advertising campaigns.

I certify that I have read and acknowledged the above paragraphs and understand this consent form and the service process. I accept full responsibility for the decision to move forward with this service.

I understand that I must prepare my eye area prior to arrival (eyelashes should be clean, dry and free of mascara, makeup and oil residue). I understand that coming to my appointment without proper preparation, Alyssa's Beauty Bar cannot guarantee lasting or satisfactory results.

I understand it is necessary to arrive on time for my appointment. I also understand the following policy: there is a 10 minute grace period, anything beyond 10 minutes late will be considered a no-show. No-show clients will be charged full price of the service booked and may not be considered for future scheduling. Cancellations within 24 hours of the appointment will be charged the full price of the service booked. Rescheduling within 24 hours of the appointment will be charged 50% of the service booked which will be credited toward the rescheduled appointment.

I understand that a service fee will be added if paying by card or afterpay. (Card - 4% fee, Afterpay - 7% fee)

Confidential Medical History

Have you used Accutane (retinoid medication that treats severe acne) in the past year?

Yes

Are you currently, or could you be pregnant?

Yes

Are you currently breastfeeding?

Yes

Are you allergic to antibiotics?

Yes

Are you allergic to latex?

Yes

Have you had permanent makeup/microblading done in the last 6 weeks?

Yes

Do you have any history of sensitivity or allergic reaction to perming solution?

Yes

Please list any medications you are currently taking (or none):

List all other allergies here, including antibiotics (or none):

List all other medical issues/illnesses here (or none):

I certify that this Informed Consent, Medical History and Release Agreement was completed by me and that all entries in it and information are true and complete to the best of my knowledge. I also certify that I have been fully informed of the risks of this service, including but not limited to: allergic reactions, sensitivity, burns, redness, hair loss, etc. Having been informed of the potential risks associated with getting the procedure, I still wish to proceed with application and I assume any and all risks that may arise from the procedure. I also certify that I take full responsibility and waive any claims against my Technician to the fullest extent permitted by law from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the service or otherwise, whether caused by the negligence or fault of either the Technician, myself, or otherwise.

Client Signature

By typing and signing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Client Name:

Date:

Client Signature:

Special requests, concerns, or remarks for technician: