Medical History Form

Full Name *

First Name Last Name

Date *

Date

Date of Birth *

Contact Number *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email Address *

example@example.com

Check the conditions that apply to you:

**Service CANNOT be performed if you are:

Pregnant or nursing

Undergoing Chemotherapy

Are under 18 years old

Are you currently taking any medication? *

Yes No

Please list any medications:

Do you have any allergies? (Including Latex, Lidocaine, or Epinephrine- each is specifically used in treatment): *

Yes No Not Sure

Swelling, redness, and slight discomfort may occur despite use of topical anesthetics.

RetinA, Alpha and Beta Hydroxy Acids must not contact the treated area.

Tanning beds and sun exposure will affect the health and longevity treated area.

Implanted color can change or fade over time due to lifestyle factors and circumstances beyond the service provider’s control. Maintenance of color by future applications is suggested to maintain desired look. A touch up session 6 weeks after initial application is provided and must be used within that specific time frame only.

It is possible that complications such as infection, color migration, poor color retention or hyperpigmentation may occur and is the responsibility of the client to see a doctor (for infection) and make subsequent appointments to correct unintended outcomes.

There are no refunds for this elective procedure and the desired shape and color is agreed to before beginning service.

Client photographs may be shown on Cole-beauty.com and social media pages such as Facebook and Instagram for promotion.

Type your name as consent to the information provided above, then click submit *

First Name Last Name

Medical History Form

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