Cosmetic Tattoo Consent Form

Cosmetic Tattoo Consent Form

This is a legal document. Please read carefully.
Client Information
Full Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Consuming alcohol within 24-48hrs prior to appointment may lead to excessive bleeding thus affecting the healed result. Have you consumed alcohol within the last 24-48 hrs?
FEMALE ONLY: Pregnant or Nursing?
Do you have a communicable disease?
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, etc.)
If yes, please identify the condition.
Are you currently taking any medication?
ie. ibuprofen, blood thinners, etc.
Medical History (e.g. Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Any known allergies?
metals, foods, etc.
Have you previously had semi permanent make up done?
If yes, machine or manual?
How did you hear about us?
If referred by someone, fill out below.
(If referred) Referred by:Name
Above is an example of brow-mapping. This as a guide to determine symmetry, arch location, size, and to create a natural design. All brows are tailored to suit individual face shape and client preference on length and thickness. When brows are pre-drawn by artist, know that it is a guide used for your intended tattoo shape thus the resulted color will be different. You will be asked a series of questions about your brow preferences during this time.
Acknowledgment and Waiver
I, CLIENT hereby consent to and authorize Kannith Meas-Truong (cosmetic tattoo artist) to perform the following procedure: BROWS / EYELINER / OTHER.
Driver’s license/ID number:
I have read and fully understand the following:

I understand that with my paid initial procedure I receive one complimentary touch-up after 4-6 weeks. If I am not able to use the touch-up (due to moving, contraindication, etc.), there Is no partial refund, as it is is complimentary and thus has no cash value. Furthermore, if I cancel within 24 hours or no-show for my touch-up appointment, my complimentary touch-up will be forfeited. Any touch-up appointment scheduled thereafter will be charged at the standard touch-up rate of $100.I acknowledge that the procedure involves inherent risks and possibilities of complications during and/or following the procedure such as: infection, allergic reaction, poor color retention, and hypo- or hyperpigmentation. I accept the permanence of this procedure and understand there is no guarantee that the color will ever fade out 100%, even several years from now. I also accept that there is no guarantee as to how long the color will remain in the skin.
Name

First NameLast Name
Client Signature
Signed Date

MonthDayYear
Date
Should be Empty:

Cosmetic Tattoo Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver