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
2 digit month, 2 digit day, 4 digit year
Date
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
Have you been diagnosed with breast cancer?
*
Have you undergone any surgical procedures related to breast cancer (e.g., mastectomy, reconstruction)?
*
If yes, roughly how long ago was the most recent surgery?
*
Are you currently undergoing any cancer treatments?
*
Do you have any known allergies or sensitivities?
*
Declaration and Agreement
Please read the following and acknowledge your agreement to these terms:
Have you researched and understood the process of Paramedical 3D Nipple tattooing?
*
Are you aware of the potential risks and complications associated with the procedure?
*
Have you consulted with a healthcare professional regarding the suitability of Paramedical 3D Nipple tattooing for your specific situation?
*
Are you willing to provide clear and honest information about your medical history and expectations?
*
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
2 digit month, 2 digit day, 4 digit year
Date
Availability & Additional Information
Do you have any specific concerns or questions about the procedure?
When would you like to schedule the Paramedical 3D Nipple tattooing session? Do you have any time constraints or preferred days/times for the appointment?
How do you prefer to be contacted by Abbey Grace Artistry to discuss your nipple tattoo application?
*
Please Select
Phonecall
Text/SMS
Email
Submit
Submit
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