Cosmetic Tattoo Consult Form

CONSULTATION FORM

Cosmetic Brow Tattoo
(THE INFORMATION SUPPLIED BELOW IS CONFIDENTIAL AND FOR PROFESSIONAL USE ONLY)
Full Name
Today's Date

MonthDayYear
DOB
Home Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Please answer the following health concerns

Rows	Yes	No
Diabetes
Health Concerns
Hepatitis
Blood Disorder
Communicable Disease
Allergies
Pregnant
Breast Feeding
Allergy to Latex
Reaction to Vaseline or Petroleum
Problems with Healing
Are you prone to Keloid Scaring
Currently undergoing Radiation or Chemo
Currently using Retin-A or Alpha Hydroxy skin care products
Currently taking acne products
Are you required to take antibiotics during dental or medical procedures
Have you ever gotten cold sore/herpes? (Even once in your life)
Have you been in a solarium/tanning bed in the past 4 weeks?

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?
Please Initial
Current concerns about your brows/Lips:
Colour and Shape I certify that I have been given the opportunity to discuss shape and to choose colour for this procedure and I am happy with both choices.
Please Initial
No alcohol & caffeine 24 hours prior to your appointment.No Asprine, Ibuprofine, Vitamine E prior to your appoinment.No strenuous work out the day of your appointment.No tanning the day of your appointment.Please arrive to your appointment with no make up around the treated area.No Botox in the treated area at least 2 weeks prior to your appointment.For Lips please hydrate and exfoliate 1 week prior to your appointment.
Avoid direct exposure of the treated area to UV ray (sun or tanning beds)No water, cleanser, creams, makeup, rough towels and other products on treated area.Do not soak the treated area in water and do not let the treated area be wet no longer than a few minutes.No Hot showers, steam room, sauna and hot spas.Do not touch, rub, pick the treated area. Let scabbing or dry skin exfoliate off naturally. Picking can cause scabbing.Avoid heavy/excessive sweating.No Facials, waxing, Tinting or threading.Visible healing will take up to 10 days, it is perfectly normal for the treated area to scab. The scab will fall off. It is normal for the colour to appear darker in the first couple of days, then fade within the 2 weeks following the treatment.
I understand that this treatment is for cosmetic enhancement purposes only and that no guarantees have been made to me regarding the results including fading, some people hold colour pigment better than others, we give no guarantees on colour fading. I am responsible for the "at home after care" which may have risk of infection or fading of pigments if not carried out fully. I consent to before and after photos of this procedure. I am aware that I cannot give blood for 4 months ( this is a universal law) I have had the opportunity to ask questions relating the this treatment I am aware that more than 1 treatment may be necessary for best results. I understand that there are no refunds given. That I read and understood all questions and information on this client detail sheet and answered all questions truthfully. Please sign if you agree to the above:
Please sign below if you agree to the above
Full Name
MonthDayYear
Date
Will you allow me to show photos of the treatment used in advertising. Please sign below if you agree to advertising:
Please sign below if you agree to advertising
Full Name
Have you ever had cosmetic tattooing before? Please select
Please select yes or no
If yes, Where and how many times?
Why have you not returned? Please select
Not SatisfiedCan't find themCostDistance
How did you hear about us?
InternetA friendDoctorAdvertising- Instagram/FacebookOther
RELEASE FORM
I hereby release the practitioner and / or any of the practitioner's associates from any and all claims, which I may have now, or in the future arising from the tattooing process. I understand that the application of tattooing is artistic in nature and in all cases experimental and that no result can be guaranteed or certain. The tattooing process has been explained to me and I have been fully informed of the procedure(s) performed. I will not hold the Therapist responsible in the event of any damage and shall not be entitled to take action against her at Law and Equity not for such treatment. I execute this release having read and fully understanding it, and do so completely voluntarily.
Client's Signature
Date

MonthDayYear
Date
Office use only
Ombre or Combination
Office use only
Pigment Shade & amount of drops
Office use only
Follow up visit booked
Should be Empty:

CONSULTATION FORM

(THE INFORMATION SUPPLIED BELOW IS CONFIDENTIAL AND FOR PROFESSIONAL USE ONLY)

RELEASE FORM