3D NIPPLE AREOLA INTAKE FORM
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Date of Birth
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Month
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Day
Year
Date
Timeless Tattoo Co. Location:
965 Dundas Street West. Unit B13, Whitby, ON.
How did you hear about our clinic?
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What is your availability for appointments?
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Evenings
Mornings
Weekends
Services you may be interested in:
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3D Post-Mastectomy Areola Tattoo $599 + HST
Body Art Tattoo $175 +HST per hour
Medical History - Do you currently have, or have you ever had any problems with the following? If yes, please explain
Keloid or Hypertrophic scars?
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Yes
No
If yes, please state location on body.
Radiation treatments?
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Yes
No
Chemotherapy?
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Yes
No
HIV / AIDS?
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Yes
No
Are you currently pregnant or breastfeeding?
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Yes
No
Cosmetic History - Have you had, or are you planning, any of the following treatments? If yes, please advise date of last:
HOW OUR CLINIC COLLECTS, USES AND DISCLOSES PATIENTS’ PERSONAL INFORMATION:
TTC understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how TTC is using and disclosing your information. The clinic will collect, use and disclose information about you for the following purposes: To advise you of our services options To send you newsletters and other information mailings To remind you of upcoming appointments To allow us to efficiently follow up for touch-ups and billing To invoice for goods and services To process credit card payments To collect unpaid accounts By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above. I have reviewed the above information that explains how your Clinic will use my personal information, and the steps your Clinic is taking to protect my information. I agree that TTC can collect, use, and disclose personal information as set out above in the information about TTC’s privacy policies. I acknowledge that any information contributed by me on this Client Personal Record and Medical History Form is true; to the best of my knowledge and that the present condition of the area that has been treated or will be treated is stated on this record. I understand that the treatment provided will rely on, in part, on the medical history I have provided, and that if this medical history is inaccurate this may negatively affect my treatment and/or result in complications.
Please sign your name:
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Signature
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