CBB Cosmetic Tattoo Health History & Consent Form

Cosmetic Tattoo Health History & Consent Form
Client Information
Patient Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Clients must be 18+ to consent and receive service.
Gender*
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*
Referral source:
History/Medical Data
Do you have currently/history of any of the following conditions?

HypertensionHeart issuesRashes or skin diseaseDiabetesProblems with healingHairloss/AlopeciaHypertrophic/Keloid scarringHistory of cold sores or fever blistersHistory of anemiaEpilepsy/SeizuresSpinal cord issuesHistory of remarkable skin sensitivityTrichotillomaniaEpilepsyLiver diseaseHIVThyroid DisturbancesHepatitisTumors/growths/cystsCancerHemophilia/blood clotting issuesOther
Describe your skin type:*
Do you have skin concerns in the brow area? If yes, please list below:
Describe your brow goals (ie. bold ‘n fluffy; natural/blends in with brow hair; natural with subtle fluff; etc.):
Are you over the age of 18?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Do you wear eye contact lenses? (If so, please do not wear to appointment)*

YesNo
Have you had botox/fillers in your forehead/upper face within 4 weeks of your appointment date?*

YesNo
Are you currently using Accutane/Retin-A Hydroxy/Glycolic Acid skincare products?*

YesNo
Are you currently taking any medications? If yes, please list them below:
*Please be advised it is recommended not to take Aspirin, NSAIDS, fish oils, or other blood-thinning medications within 7 days of appointment.
Please list any allergies you have below:
The following medical conditions require a note from your doctor giving consent for cosmetic tattooing:
- Type I/II Diabetes
- Hypertensive Disorders
- Auto-Immune Diseases
- Thyroid/Grave's Disease
- Any other medical condition that causes slow healing or an increased risk of infection
Technicians make no attempt or claim to practice medicine. Though rare, some individuals will have complications related to cosmetic tattoo applications which are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible or obvious reasons to restrict you from receiving a tattoo, it is not the technician's position to determine otherwise. You must approve of the procedure and the color before the application of your new tattoo.
Authorization
- I confirm that all information given in this form is true, complete, and accurate.
- I released this organization for any responsibility in case of accident, illness, or injury.
- I understand that with time the pigment can fade and will change according to metabolism, skin type, sun/UV exposure, medication, age, smoking, alcohol, Retin-A/Retinol/Glycolic acids, etc.
- I understand that the process used to apply color is not a one-step process and may require subsequent visits to achieve desired results. I further understand that the fee includes my first visit and one touch-up visit within 5-9 weeks of first session and the result of the procedure will be a permanent change.
- I understand the nature of the procedure and possible complications, reactions or adverse effects that may occur as a result of the applied pigments. I fully understand this is a tattooing process, and have discussed any medical conditions.
- I acknowledge that no assurance can be guaranteed about the outcome.
- I have read through the pre-instruction and aftercare information and agree to strictly comply with said recommendations. I understand that if aftercare is not followed correctly, infection may occur.
- I understand that taking before and after pictures may be required and allow Cassandra B Beauty to use the photos for marketing or promotional services.
- I acknowledge by signing below, that I have been given the full opportunity to ask any and all questions which I might have about obtaining this procedure(s) from Cassandra. I also acknowledge that all of my questions have been answered below to my full and total satisfaction. I specifically acknowledge that I have been advised of the fact and matters set below, and I agree as follows.
- I understand the deposit/cost of the procedure is non-refundable.
I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Cassandra Bowers shall perform permanent application of pigments to the skin of the releaser by way of cosmetic tattooing. The releaser has been informed as to the methods and procedures concerning the result of such treatments. An allergy scratch test may also be performed prior to the procedure at the request of the client, however it does not guarantee that you may not develop an allergic reaction after the full procedure. Permanent cosmetics cannot be performed if you are pregnant/breastfeeding, or under the age of 18. I hereby release, acquit and discharge Cassandra Bowers and any and all persons which are or might be claimed to be liable to me from all claims and demands or whatever nature, actions and causes of action, damages, cost, loss of service, expenses and compensation on account or in any way growing out of personal injuries and property damage to result at any time in the future, whether or not they are in contemplation of parties at the present time and whether or not they arise following the execution of the release as the result of treatment procedure rendered. Releaser agrees to indemnify the hold harmless of Cassandra Bowers for any loss, damage, claim, injury, or expense asserted against myself.
Client Signature*

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Date*

MonthDayYear
Date
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to be spread mainly from person-to-person contact. As a a result provincial and federal health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups and people.

Cassandra B Beauty has put in place preventative measures to reduce the spread of COVID-19 with strict cleaning and sanitation measures as well as a requirement to wear masks during appointments. Attending to appointments in the studio has the possibility to increase your risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 by attending the appointment and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed or infected by COVID-19 at MicroBeauty Studio may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and guests.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my family may experience or incur in connection with my appointment attendance with Cassandra B Beauty.
Client Initials*

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Cosmetic Tattoo Health History & Consent Form

Client Information

History/Medical Data

Authorization