Tattoo New Client Medical History Form

Tattoo Medical History Form
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Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your birthdate?*

MonthDayYear
Date
How did you hear about Emily Mercer Beauty?*
Would you like to join EMB's mailing list?*

YesNo
Do you have or have you recently had any of the following?
Do you tint your eyebrows?*

YesNo
Date of last tinting:*

MonthDayYear
Date
Do you wear eyelash extensions?*

YesNo
Do you use an eyelash serum?*

YesNo
Do you have eye implants?*

YesNo
Do you have Rosacea?*

YesNo
I understand that having Rocacea are contraindications in permanent makeup. Due to the over-production of the oil glands in the skin and the size of the pores, the pigment can and will heal more solid/powdered. The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. These are all potential risks you accept may or can happen.

If you were previously on Accutane, the skin integrity has changed. There is a higher chance that the pigment will not retain, fade rapidly or change in color.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur. I wish to proceed.

Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures may not be performed. This is left up to Emily Mercer Beauty. All services performed are non-refundable.
Do you have oily skin?*

YesNo
I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup. Due to the over-production of the oil glands in the skin and the size of the pores, the pigment can and will heal more solid/powdered. The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. These are all potential risks you accept may or can happen.

If you were previously on Accutane, the skin integrity has changed. There is a higher chance that the pigment will not retain, fade rapidly or change in color.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur. I wish to proceed.

Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures may not be performed. This is left up to Emily Mercer Beauty. All services performed are non-refundable.
Do you frequently exercise (3+ days a week or more)?*

YesNo
I understand that frequent exercise (3+ days a week or more) can and will cause the hair strokes or other areas of the tattoo to appear blurry under the skin, change in color, fade prematurely, or not retain at all.

Due to the sweat (salt) that your body produces will impact the result. In permanent makeup, saline (salt) is used to remove or lighten pigment. Even after the results are healed sweat will still impact the longevity of the procedure.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her associates harmless if above said risks occur.

I wish to proceed with the application of permanent makeup.

Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures will not be performed. This is up to Emily Mercer Beauty's discretion.

All services are non-refundable.
Do you have Fitzpatrick Skin Type 1 or Fitzpatrick Skin Type 2?*

YesNo
I have been informed that having a Fitzpatrick skin types of a 1 or 2 (red head, dark red, light red, red undertones, strawberry blonde and blonde) can and may cause the pigments to: fade prematurely, look more blurred or powdered under the skin, the hair strokes can appear blotchy and spread, change in color or not retain at all. With the more sensitive skin types bleeding may occur and the procedure will be stopped. We as technicians have zero control over your skin or how it heals.

Emily Mercer Beauty also reserves the right to refuse future services should the above risks occur.

I accept these risks and will hold Emily Mercer Beauty and/or her associates harmless if the above said risks occur.

I take full responsibility and accept that the above mentioned risks could happen and is at no fault of the technician.

All services performed will be non-refundable and final.
Do you have Trichotillomania (Pulling)?*

YesNo
I understand that Trichotillomania/Pulling is a contraindication in permanent makeup.

Due to the change in texture of the skin and scar tissue the pigment can and will heal more solid/powdered. The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. These are all potential risks.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur.

Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures may not be performed. This is left up to Emily Mercer Beauty's discretion.

All services performed are non-refundable.
Do you have Vitiligo?*

YesNo
I understand that Vitiligo is an auto-immune disease and is a contraindication in permanent makeup. Due to the change in texture of the skin and lack of Follicles, the pigment can and may heal more solid/powdered. The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. These are all potential risks.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur. Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures may not be performed. This is left up to Emily Mercer Beauty's discretion.

All services performed are non-refundable.

You will be responsible for maintaining your follow-ups with a technician at the Emily Mercer Beauty studio. Fees will apply.

I fully understand above said risks and wish to proceed with the procedure.
Do you have any auto-immune disorders (other than Vitiligo)?*

YesNo
I understand that having an auto-immune disease is a contraindication in permanent makeup. Due to the illness/disease and the medications taken to treat the illness or disease, the pigment can and may heal more solid/powdered. The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. These are all potential risks.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur. Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures may not be performed. This is left up to Emily Mercer Beauty's discretion.

All services performed are non-refundable.

You will be responsible for maintaining your follow-ups. Fees will apply.

I fully understand above said risks and wish to proceed with the procedure.
Do you have Alopecia?*

YesNo
I understand that Alopecia is an auto-immune disease and is a contraindication in permanent makeup. Due to the change in texture of the skin and lack of follicles, the pigment can and may heal more solid/powdered. The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. These are all potential risks.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur. Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures may not be performed. This is left up to Emily Mercer Beauty's discretion.

All services performed are non-refundable.

You will be responsible for maintaining your follow-ups. Fees will apply.

I fully understand above said risks and wish to proceed with the procedure.
Do you take medications for your thyroid?*

YesNo
I have been informed that thyroid medicines can and may cause the pigments to: fade prematurely, look more blurred or powdered under the skin change in color or not retain at all. I accept these risks and will hold Emily Mercer Beauty and/or her associates harmless if above said risks occur. I take full responsibility and accept that this could happen.

All services performed will be non-refundable and final.
Do you use Accutane or acne treatments?*

YesNo
I understand that using acne medications in topical or pill form are contraindications in permanent makeup. Although creams are not applied directly to the eyebrows, they can travel up to 2 inches under the skin. If taking a pill for your acne, there is no way of knowing how it will affect the skin. However, knowing they are used in treatments of skin conditions, they can, may or will affect the results.

Due to the chemicals/acids found in these products the pigment can appear blurry under the skin, change in color, fade prematurely, cause the skin to bleed or not retain at all. This goes for the Hair Stroke and the Ombre/Powdered brow techniques. If you bleed, the procedure may or will have to cease. These are all potential risks that you accept can or will happen.

After the procedure is healed and you resume using the above-mentioned products (creams/pills), they will still impact the longevity of the procedure.

If you are on a pill form of acne medication and do not discontinue use, we have no way of knowing the outcome of your procedure as we are not doctors. You are choosing to proceed with the procedure and fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur. No guarantees have been made to me as to the outcome of the procedure.

I wish to proceed knowing above said risks can occur.

Appointments will not be made any sooner if said risks occur, there may be a chance that any future procedures will not be performed. This is left up to your discretion.

All services performed are final and non-refundable.
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy Acid?*

YesNo
I understand that using anti-aging products containing retinols, salicylic, lactic acid, alpha hydroxy and the like are contraindications. Due to the chemicals/acids found in these products the pigment can appear blurry under the skin, change in color, fade prematurely or not retain at all. This goes for the Hair Stroke and the Ombre techniques. These products also can cause bleeding. If you bleed, the procedure may or will have to cease. These are all potential risks that you accept can or will happen.

After the procedure is healed and you resume using the above-mentioned products, they will still impact the longevity of the procedure. The creams and acids can travel up to 2 inches under the skin and will cause premature fading, blurring, color changes or no retention at all.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty's, and her Associates harmless if above said risks occur. No guarantees have been made to me as to the outcome of the procedure.

I wish to proceed knowing above said risks can occur.

Appointments will not be made any sooner if said risks occur and there may be a chance that any future procedures will not be performed. This is left up to Emily Mercer Beauty's discretion.

All services performed are final and non-refundable.
Have you had your brows previously done?*

YesNo
If yes, when? *

MonthDayYear
Date
I have been fully informed and understand that having my brows previously done by another technician will impact my results of this corrective procedure.

Due to underlying scar tissue the pigment will and can fade prematurely, look blotchy, blurred, heal unevenly, change in color or not retain at all.

This is an attempt to correct a procedure that was originally done by another technician and absolutely no guarantees have been made to me as to the final result.

I accept full responsibility and will hold Emily Mercer Beauty and/or her associates harmless if the above said risks occur.

All services performed will be non-refundable and Emily Mercer Beauty reserves the right to refuse any future services if she feels that it is non productive to proceed.

I wish to proceed with the procedure and accept all the possible.
Do you tan (by booth or outside)?*

YesNo
I understand that having tan skin at the time of the appointment is a contraindication. Tan skin will bleed, possibly heal darker and can or will fade to an ashy color as the tan fades. The pigment can and will heal more solid/powdered. The hair strokes can look thicker, appear blurry under the skin, change in color, fade prematurely or not retain at all. These are all potential risks you accept may or can happen.

No guarantees have been made to me as to the final results.

I fully understand and accept the above said risks and will hold Emily Mercer Beauty and/or her Associates harmless if above said risks occur. Appointments will not be made any sooner if the above said risks occur and there may be a chance that any future procedures may not be performed. This is left up to Emily Mercer Beauty's discretion. I wish to proceed.

All services performed are non-refundable.
Do you wear contacts?*

YesNo
Do you have Diabetes?*

YesNo
Do you have Hepatitis A, B, C or D?*

YesNo
Do you bleed easily?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Do you have abnormal heart conditions?*

YesNo
Do you have Psoriasis?*

YesNo
Have you gone through Chemotherapy or Radiation?*

YesNo
Have you had Tumors/Growths/or Cysts?*

YesNo
Are you taking any blood thinners such as: Aspirin, Ibuprofen, Alcohol, Fish Oil, etc.?*

YesNo
Do you have any allergies to Metals, Foods, Plants, etc. ?*

YesNo
If yes, please list your allergies below:*
Allergic reaction to any medications and/or topical solutions such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Cabopol, Lecithin, Propylene Glycol, or Vitamine E Acetate?*

YesNo
If allergic to any medication not listed above, then please add your allergies below:*
Allergy to Grapeseed Oil?*

YesNo

To avoid unforeseen complications, please answer the following questions: *

	Choose One
Do you have any history of cold sores, herpes, or fever blisters?
Are you sensitive to Latex/Lidocaine/Epinephrine?
Do you have problems with healing?
Previous problems with tattoos?
Are you currently undergoing radiation or chemotherapy?
Are you currently taking any chemotherapy medications?
Are you allergic to any metal?
Previous Permanent Makeup/Microblading?
Have you had tattoos before?
Medications including immunosuppressive, such as anti-inflammatory or steroids?
Are you allergic to topical anesthetics?
Is there any history of skin diseases or remarkable skin sensitivities?
Are you Pregnant/Nursing/Don’t Know?
Are you required to take antibiotics during dental or invasive medical procedures?
Are you currently taking medication for high or low blood pressure?
Frequent Sun Exposure/Tanning Beds?
Are you planning on any facial surgery in the near future? (Face lift, eyelids, or brow lift)?
Have you had COVID-19?
Have you gotten the COVID-19 vaccine?

Have you done a Chemical Peel?*

YesNo
If yes, date of last Peel:*

MonthDayYear
Date
Do you, or have you had, any of the following:*

TuberculosisBleeding DisorderTrichotillomaniaAllergies to makeupMenopause/Run Hot/Frequent Hot FlashesMRSA/STAPHOn Blood ThinnersEczema/DermatitisAccutane treatmentHepatitis/HIVKidney Disease /TransplantLiver Disease/CirrhosisKeloidsDiabetes (type 1,II)Stroke/ParalysisHeart Conditions/Pace maker/DefibrillatorThyroid Issues/MedsHyper-pigmentationHypo-pigmentationShortness of breathEpilepsy/seizuresSmokerCataract surgeryTear duct plugsRefractive eye surgeryEyelid surgeryLasik surgeryGlaucomaCOPDOrgan transplantVitiligoCold soresShingles (on face)Rosacea (on the face)Use Lash/Brow SerumHerpes SimplexOcular HerpesSeverely oily SkinOily SkinOily T-ZoneCombination SkinScar/s in area to be tattooedHead Injury/Trauma (hit the head, accidents)NONE OF THE ABOVEOther
Do you have any other medical conditions not listed?*

YesNo
If yes, then please list:*
Have you had Botox?*

YesNo
If yes, last treatment date:*

MonthDayYear
Date
Have you had a baby in the last year?*

YesNo
If yes, please list date of birth.*

MonthDayYear
Date
Other Medical Conditions/Surgeries. Please explain any checked question. List any other medical conditions or allergies. List all medications. If not applicable, please put n/a.*
Are you allergic to Shea, Mango, and Aloe Butters, Coconut Bran, Sunflower and Rice Oils, Rosemary Oleoresin, Green Tea, Vitamin E Complex, Papaya, Coconut or Arvenis Peppermint Essential Oil?*

YesNo
What skincare products do you use? (List any cleansers, toners, serums, moisturizers, etc.)*
Anesthetic
The topical anesthetic used may contain Lignocaine and Tetracaine Prilocaine. Do you give your approval for these creams and lotions to be used before and during your procedure?*

YesNo
I certify that my answers are true and complete to the best of my knowledge.
Signature*

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Tattoo Medical History Form

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