CONFIDENTIAL • SECURE • 8 MINUTES

Medical Health
& Consent

A calm, guided consultation form designed to help us understand your health history and tailor your permanent makeup treatment safely.

Before you begin

Have these ready:

Your medication list
Your GP details, if applicable
Details of previous PMU treatments

Your progress is divided into short, focused steps.

PRIVATE BY DESIGN

Your safety comes first.

Your complete answers are stored in WordPress for authorised review. Email notifications contain no medical answers.

Photo marketing consent is separate from treatment consent, so you remain fully in control.

Your consultation starts here

Complete the six short sections below. Your progress advances after you click Continue and the current section passes validation. You can move back before submitting.

About you

Fields marked with * are required. Your answers are treated as confidential health information.

Full name

Date of birth

Email address

Contact number

Full address

Important notice
Clients with medical conditions who are under the care of a GP or consultant and/or are taking prescribed medication must provide a GP referral before treatment. Without a GP referral, we are unable to perform the procedure.

Medical history

Please answer honestly so we can assess whether treatment is suitable for you.

Medication taken in the last 6 months

In the last 2 days, have you taken Aspirin, Ibuprofen or alcohol?

Yes No

Have you received chemotherapy or radiation treatment in the last year?

Yes No

If applicable, provide your GP’s full name and address

Allergy information

Select every substance that has caused an allergic reaction. If none apply, choose “No known reactions”.

Anaesthetics — which ones?

Other allergies

General health

These questions help identify contraindications and whether a GP referral is required.

Have you had a dental injection to numb your mouth?

Yes No

Are you currently pregnant or breastfeeding?

Yes No

Please note: We cannot treat clients who are pregnant or breastfeeding.

Do you have an MRI scan scheduled in the next 3 months?

Yes No

Do you have Laser or IPL appointments in the next 3 months?

Yes No

Do you donate blood?

Yes No

Do you require antibiotics before dental procedures?

Yes No

Have you had Botox or other injectables?

Yes No

If yes, when was your most recent injectable treatment?

Are you currently under the care of a doctor or hospital specialist?

Yes No

If you are under the care of a doctor or specialist, a GP referral is required before treatment.

Patch testing for allergies

Please choose the statement that applies to you.

Patch test declaration

A — I understand a patch test may help identify potential reactions but is not fully conclusive. I choose to waive my allergy test and proceed. B — I have undergone / been offered a patch test and release the technician from liability related to allergic reactions.

I have read and understood the patch-testing section.

Typed signature — full legal name

Signature date

Previous semi-permanent makeup

Please tell us about any previous work so we can plan your treatment safely.

Have you had previous semi-permanent makeup?

Yes No

If yes, provide details

I consent to further semi-permanent makeup work being carried out at my request and with full understanding of the information provided.

Typed signature — further PMU consent

May Eye Line PMU use treatment photos for social media, the website and marketing?

Yes, I consent No, I do not consent

Typed name for photo-consent record

Permanent cosmetic / medical micropigmentation consent

I authorise the technician to perform permanent cosmetic or medical enhancement. If an unforeseen condition arises during the procedure, I authorise the technician to use their professional judgement as necessary.

I understand that:

Permanent cosmetics are an advanced form of tattooing.
I am responsible for agreeing to shape, position and colour during consultation.
Patch tests do not guarantee that a future reaction will not occur.
Allergic reactions to pigments or anaesthetics are rare but possible, and I accept responsibility for disclosing relevant information.
Pigment may fade over 1–3 years and may leave a light residue.
Sterile, disposable needles are used.
Multiple sessions may be required and results cannot be guaranteed.
A top-up may be required 4–6 weeks after the initial treatment and is included only within 2 months.
The procedure may cause discomfort, swelling, redness or bruising for 1–4 days.
Results depend on medication, skin type, sun exposure, smoking, lifestyle, diet and aftercare.
Colour may appear 30–50% darker initially and lighten over 4–10 days; healed colour is assessed after about one month.
Laser treatments, chemical peels, cosmetic procedures, injectables and sun exposure may alter results.
No refund is given if I choose not to attend my top-up appointment.
I must follow aftercare instructions and contact my GP immediately if infection occurs.
I confirm I am over 18 and not under the influence of drugs or alcohol.

Colour boost pricing

Annual top-up: £180
Over 12 months: £275
Dark Lip Neutralisation — annual top-up: £200
Dark Lip Neutralisation — over 12 months: £295

I understand and agree to the colour boost pricing.

I confirm that I have read, understood and agree to all information in this consent form, and I choose to proceed of my own free will.

I explicitly consent to Eye Line PMU collecting and securely storing the health information in this form to assess my suitability for treatment. I have read the Privacy Policy.

Read the Eye Line PMU Privacy Policy

Final typed signature — full legal name

Date

Questions before you submit?

Call 07580 707976 or email masa@eyelinepmu.co.uk. We are happy to explain any part of this form.

CONFIDENTIAL • SECURE • 8 MINUTES

Medical Health
& Consent

Before you begin

PRIVATE BY DESIGN

Your safety comes first.

Your consultation starts here

Questions before you submit?

Explore EyeLinePMU

Find your next little detail.

What would you love to enhance?

CONFIDENTIAL • SECURE • 8 MINUTES

Medical Health& Consent

Before you begin

PRIVATE BY DESIGN

Your safety comes first.

Your consultation starts here

About you

Medical history

Allergy information

General health

Patch testing for allergies

Previous semi-permanent makeup

Permanent cosmetic / medical micropigmentation consent

Colour boost pricing

Questions before you submit?

Medical Health
& Consent