Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Gender
*
Please Select
Male
Female
Other
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Occupation
*
Application Questions
Please read carefully and respond honestly to determine your suitability for this service.
Are you currently taking any medications?
*
Please Select
Yes
No
If yes, please provide details
Are you able to use topical anaesthetic? (lignocaine, tetracaine, prilocaine, epinephrine)
*
Please Select
Yes
No
Are you pregnant, planning pregnancy or breastfeeding?
*
Please Select
Yes
No
Do you have oily skin?
*
Please Select
Yes
No
Do you have any health concerns?
*
Please Select
Yes
No
Are you iron deficient or anaemic?
*
Please Select
Yes
No
Are you prone to keloid scarring?
*
Please Select
Yes
No
Do you suffer from anxiety/depressions?
*
Please Select
Yes
No
File Uploads
Please attach photos/files as requested below.
Please attach a clear image of your FULL FACE with no make-up on (Please take in clear natural light)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please attach a clear image of your LEFT EYEBROW with no make-up (Please take in clear natural light)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please attach a clear image of your RIGHT EYEBROW with no make-up (Please take in clear natural light)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please attach a clear image of your driver’s license or ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Declaration and Agreement
Please read the following and acknowledge your agreement to these terms:
I understand that tattooing is custom, artistic in nature and no results or expectations can be guaranteed.
*
Yes, I understand
I understand that a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin to it’s exact appearance before being tattooed.
*
Yes, I understand
I have read and understand the information provided to me in the above information provided and have answered each question truthfully.
*
Yes, I understand and accept
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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