Cosmetic Tattoo Consent Form

Cosmetic Tattoo Consent Form

Pink Fluff Tattoo
Client Details
Name*

First NameLast Name
Location*

Cloverdale, BCBelfast, NI
Date of Birth*

MonthDayYear
Age*
Date of procedure*

MonthDayYear
What procedure are you booking?*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
Social Media Handle
I have read the Terms & Conditions (T&Cs) on Pinkflufftattoo.com

YesNo

Have you had or currently. have any of the following

	Yes	No
Currently Pregnant / Breastfeeding
Has or any family history of Diabetes
Has Hepatitis A B C D
Had any face surgery
Had Brow Tint or Wax in the last 48 hours
Has Autoimmune disorder
Has very oily skin
Taking or have taken acne treatments such as accutane in the past 12 months
Had a Tan treatment in the last 48 hours
Do you use facial care treatments? Retinol, Acids etc
Have you had previous cosmetic tattoo on area in question (If YES, please attach a clear photo below)
Have lip filler
In last 4 weeks had Botox or Filler?
(Lip blush procedure) Do you have a history of cold sores?
HIV or Transmittable Diseases
Heart disease / high or low blood pressure
Eczema/psoriasis/diabetes/epilepsy/haemophilia/
Do you have hyperpigmentation/ hypopigmentation
Do you suffer from keloid scarring
Allergic to specific foods?
Allergic to anaesthetic / lidocaine / lanolin
Allergic to wax crayons / Vaseline /isopropyl alcohol
Allergic to any essential oils; lavandula augustifolia, melaleuca, mentha piperita
Are you currently having or expected to have any medical treatment that may interfere with the healing of your procedure?
Taking blood thinners such as: Aspirin, Ibuprofen or Alcohol

Medical History
If you answered YES, please give more details
If you answered yes to any of the above medical conditions, acknowledge you have been advised by your artist the risks that come with proceeding with the procedure. By ticking these boxes you are giving your full consent and take full liability to do so at your own risk.*

Yes, i give my full consent to proceed at my own riskYes, i have been thoroughly advised on the risks with proceeding with the procedure
Please list down any medications you are taking
Upload photo of previous work

Browse Files
Please ensure photo is clear using natural light Cancelof
Signature*

Clear

Contact in case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number

CONSENT

I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and consent to receiving the cosmotic tattoo procedure.

I am aware of the possible risks such as: infection, scarring, or inconsistent colour.

I understand that this cosmetic procedure is not fully permanent and might result in fading over time. I will strictly adhere to aftercare instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my responsibility.

I understand colour is affected by skin type, orginial colour, age, metabolism, exposure to sun, smoking, medication and skincare treatments.

I am aware my skin may reject some pigment due to medication, skin characteristics, pH level, alcohol intake and post pecedure aftercare.

I am aware that it may take numerous touch-ups to achieve desired results.

I understand that yearly touchups are advised to up keep long lasting desired results (for brows).

I understand that botox or filler treatments surrounding the area can alter the position of the eyebrow/lips wether performed prior to treatment or after.

I have advised my pmu artist of any allergies i suffer from. I acknowledge that it is not possible for the artist to determine whether i might have an allergic reaction to the permanent makeup process and further acknowledge that such reaction is possible. I acknowledge an allergic reaction could result in discolouration, poor scarring and other skin conditions.

I understand that before and after photographs will be taken for comparison and may be posted online.

I understand that the deposit paid at the time of booking is non refundable.

I understand that once my procedure is carried out and paid for in full i will not be eligible for a refund.

I give my written consent to the artist to carry out the procedure of my choice, shape and colour as agreed to and requested by me on.

I release my artist and representatives of all claims and injury seen or unseen that may occur as a result of this prodecure.

I HEREBY CONSENT TO THE APPLICATION OF MICROPIGMENTATION. I HAVE READ AND UNDERSTOOD ALL POINTS IN THE PROCEDURE CONSENT FORM AND ACCEPT FULL RESPONSIBILITY FOR ANY COMPLICATION THAT MAY ARISE DURING OR FOLLOWING APPLICATION PROCEDURES. I UNDERSTAND NO REFUNDS WILL BE GIVEN FOR IMCOMPLETE TREATMENTS OR FOR POOR SATURATION.
Signature

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How did you hear about Pink Fluff Tattoo?
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