MARI ZONE · PMU
Please complete this form honestly before your appointment. This declaration is reviewed with your PMU artist and is intended for in-studio use.
Client Information
Full Name: ________________________________
Date of Birth: _______________________________
Phone / E-mail: ______________________________
Medical Questionnaire
Please check Yes or No for each item. Do you currently have, or have you ever had, any of the following?
[ ] Yes [ ] No — Pregnancy or currently breastfeeding
[ ] Yes [ ] No — Diabetes or autoimmune disorders
[ ] Yes [ ] No — Blood-thinning medication or hemophilia
[ ] Yes [ ] No — Active skin conditions in the treatment area
[ ] Yes [ ] No — History of keloid scarring
[ ] Yes [ ] No — Use of Roaccutane / Isotretinoin in the past 6 months
[ ] Yes [ ] No — Allergies to pigments, lidocaine/anesthetics, or latex
[ ] Yes [ ] No — Cardiovascular conditions or pacemaker
[ ] Yes [ ] No — Hepatitis B/C, HIV, or other blood-borne infections
Client Declaration & Consent
I declare that I have answered the health questionnaire truthfully and completely. I understand that Semi-Permanent Makeup involves penetrating the skin with sterile micro-needles and implanting pigments. I understand that the final result depends on individual skin type, metabolism, health, and strict adherence to aftercare guidelines; exact colour and shape symmetry cannot be guaranteed. I acknowledge that I have received, read, and agree to follow the aftercare instructions. I confirm that I am at least 18 years of age and not under the influence of alcohol, drugs, or medications that impair judgment.
Client Signature: _________________________
Date: _____________________________________
Deposit, Touch-up & Cancellation Policy
Deposit (Aanbetaling): A non-refundable €30 deposit is required at booking and is deducted from the treatment cost. Touch-up (Nabehandeling): a touch-up is charged separately at €100 and should be scheduled 6–8 weeks after the primary treatment. Cancellation: with more than 48 hours’ notice, one free reschedule is possible and the deposit transfers to the new date. With less than 48 hours’ notice, the deposit is forfeited. No-shows forfeit the deposit and must settle any outstanding balance before a future booking. Arrivals more than 15 minutes late may result in cancellation and forfeiture of the deposit.