Ariyah Beauty
Online Cosmetic Tattoo Consult Form
Full Name
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First Name
Last Name
Birth Date
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Day
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Month
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Mobile Phone Number
Email
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example@example.com
Due to new regulations for compunded number creams, Ariyah Beauty can not purchase or supply numbering cream on your behalf. We are supplied by a pharmacist who will complete your numbing cream order and post to the salon. We assist you in applying the cream when you arrive at the Salon.
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I understand and accept to comply with the pharmacy regulations
Do you have any known allergies?
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Yes
No
If yes, please list here
List any known allergies
Are you currently taking any medications or supplements?
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Yes
No
If yes, please list here
List all medications or supplements
Do you have any previous eyeliner, lip or brow tattoo done elsewhere?
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Yes - fill out form below
No
If yes, how old is the tattoo?
List in weeks, month and year
Are you over 18 years old?
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Yes
No
What is your type of skin?
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Normal
Sensitive
Combination Oily
Normal/Dry
Oily
Oily/Acne
How is your skin?
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Thick with enlarged pores
Thin with visible veins
Sundamaged
Dry skin in the eyebrows
None of the above
Other
Please select any lifestyle factors relevant to you
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Outdoors often
Excerise regularly
Swim in pool or at the beach
Smoker
In humid or hot environments often
None of the above
What are your main concerns with your eyeliner, lips or brows?
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Brows too thin
Brows too thick
Brows have bald patches
I want a better shape
I can't draw them on
Lips are patchy
Lip line is not defined
Other
Which Cosmetic Tattoo procedure do you wish to have?
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Ombre Brows
Feather Brows
Combination Brows
Lip Blush Tattoo
Top Eyeliner Tattoo
Lash Line Enhancement Tattoo
Not sure
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 pigment colour better than others for reasons out of our control, so no exact timeframe of colour last is given
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Yes
No
I am responsible for the 'at home after care' post procedure which may have risk of infection or premature fading of colour pigment if the after care is not followed properly. Your hands must be washed before coming in contact with the tattoo throughout the entire healing process. It is extremely important to follow all after care information for the instructed timeframe
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Yes, I agree to follow the after care instructions
No, I can't follow them
I am aware I have the opportunity to ask questions relating to this treatment prior to, and during the procedure if there is anything I do not understand or know
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Yes
No
I am aware I will need to return for the 6 week touch up treatment to finalise the procedure and get the final result. In SOME cases (after care not being followed correctly, oily skin type, medical conditions, lifestyle, very light colour choices or request of very light coverage of tattoo), an additional touch up appointment may be necessary to attain optimum results. This is a charged at an additional fee of $150 and must be done 8-12 weeks post the touch up appointment
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Yes, I agree and understand
No, I don't agree or understand
I understand I must wait at least 4-6 weeks for healed results to be seen. At the 4-6 week touch up appointment any colour changes, shape alterations or other adjustments will be done them and no sooner due to risk or scarring
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Yes, I agree and understand
No
I understand that allergic reactions can occur at any point in my life to anything and that allergies can develop over the duration of time, even if an initial exposure didn't cause a reaction. Because of this, I understand and accept that allergic reactions are possible to this treatment and I cannot hold Ariyah Beauty responsible or try to claim from Ariyah Beauty for cost of medical expenses in the event a reaction should occur
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Yes, I agree and understand
No, I do not agree
Should an allergic reaction occur I will seek the advise of my medical practitioner and inform Ariyah Beauty of the reaction and outcome
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Yes
No
I understand application of Cosmetic Tattooing can cause some discomfort
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Yes
No
I am aware that I can not give blood for 4 months post the touch up treatment (this is a universal tattoo law)
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Yes
No
Why do you want to have cosmetic tattooing?
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Example: to enhance my shape
Do you have any special occasions coming up? Eg. Wedding, Holiday, Birthday
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I acknowledge that I will be shown all equipment used for my procedure is new and sterile tools. This will be for every treatment
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Yes, I understand
No
I accept full responsibility for the shape, colour and position of the cosmetic tattoo as per the 'pre treatment design' that will be drawn on prior to commencing the procedure. I understand I have the option to ask for any changes to be made to this pre design until I am confident and happy to go ahead
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Yes, I understand
No
I have read and understood all questions and information on this form and have answered truthfully
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Yes
No
I understand no refunds are given under any circumstances
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Yes, I understand
No
I agree to for the purpose of documentation, consent to the taking before, during and after photographs of the procedure for record purposes and for the use on social media
Yes to all above
No
Yes but not for social media. For records only.
Please upload a close, CLEAR front photo of your brows, eyes or lips - one with your eyes open and another closed. (Please ensure there is lots of good lighting) and upload below.
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UPLOAD BROW OR LIP SELFIE
Drag and drop files here
Choose a file
Upload your brow, eye or lip selfie
Cancel
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