#103 7228 192 St Surrey BC
778-889-0620
Permanent Makeup Consent & Medical History Form
Client Name
(Required)
Full Name
Phone
(Required)
Email
(Required)
DOB (18+ only)
(Required)
MM slash DD slash YYYY
Procedure Requested
(Required)
Lips
Brows
Eyeliner
Correction / Neutralization
MEDICAL HISTORY (YES / NO)
Are you pregnant?
(Required)
Yes
No
Breastfeeding?
(Required)
Yes
No
Are you diabetic?
(Required)
Yes
No
On blood thinners?
(Required)
Yes
No
Do you have autoimmune disorders?
(Required)
Yes
No
History of keloids or hypertrophic scars?
(Required)
Yes
No
History of cold sores/herpes (for lips)?
(Required)
Yes
No
Are you on Accutane/Retinol?
(Required)
Yes
No
Any allergies to lidocaine/numbing/inks?
(Required)
Yes
No
Skin conditions (eczema, psoriasis)?
(Required)
Yes
No
Have you had previous PMU on the same area?
(Required)
Yes
No
Any cosmetic procedures in last 4 weeks?
(Required)
Yes
No
If YES to any above, please explain:
SKIN & LIFESTYLE QUESTIONS
Skin Type
(Required)
Normal
Oily
Dry
Combination
Sensitive
Do you tan easily or have sun-damaged skin?
(Required)
Yes
No
Do you pick/scratch your skin?
(Required)
Yes
No
Do you have large pores or textured skin?
(Required)
Yes
No
Do you smoke or vape?
(Required)
Yes
No
Are you prone to hyperpigmentation/dark spots?
(Required)
Yes
No
CONSENT & LIABILITY WAIVER
(Required)
CONSENT & LIABILITY WAIVER By submitting this form, I agree to the following terms regarding my treatment at RK Beauty Club. 1. Informed Consent, Capacity & Voluntary Decision I confirm that I am 18 years of age or older (or have a legal guardian present) and have the legal capacity to consent. I have read and understood the details of the treatment I am requesting. I have had the opportunity to ask questions regarding the procedure, risks, benefits, alternatives, and expected outcomes, and all questions have been answered to my satisfaction. I confirm that I am choosing this treatment voluntarily, without coercion, and I understand I may withdraw my consent at any time before or during the procedure. 2. Medical Accuracy & Responsibility I certify that the medical history and health information I have provided is truthful, accurate, and complete. I understand that undisclosed conditions, allergies, or medications (e.g., blood thinners, Accutane) may affect my safety and the treatment outcome. I assume full responsibility for any adverse reactions resulting from my failure to disclose such information. 3. Risk Acknowledgement & No Guarantees I understand that all aesthetic procedures carry inherent risks, including but not limited to: pain, redness, swelling, blistering, scarring, discoloration, sensitivity, infection, allergic reactions, and healing variations. I acknowledge that results are not guaranteed, may vary by individual, and that "touch-ups" or additional sessions may be required at my own expense. 4. Aftercare Commitment I agree to strictly follow all pre- and post-treatment instructions provided by RK Beauty Club. I understand that failure to follow these instructions may increase the risk of complications, infection, or altered results, for which the clinic cannot be held responsible. 5. Financial Policy & Refunds I understand and agree to the clinic’s financial policy. I acknowledge that all payments and deposits are non-refundable (except where required by law). I also agree to provide at least 48 hours' notice for cancellations to avoid forfeiture of deposits or cancellation fees. 6. Release of Liability I hereby release, waive, and discharge RK Beauty Club, its owners, technicians, and staff from any liability, claims, or demands related to treatment outcomes, complications, or reactions that result from my consented procedure, except in cases of proven gross negligence. 7. Data Privacy & Media Release Privacy: I understand that my personal and medical information will be collected, stored, and used in accordance with applicable privacy laws (e.g., PIPA/PIPEDA). Media: Unless I have explicitly indicated otherwise in writing, I grant permission for before/after photos and videos of my treatment to be used for training, educational, and marketing purposes.
Consent
(Required)
I have read, understood, and agree to the Consent & Liability Waiver terms.
Signature:
(Required)
Type in Your Full Name
