Body Art Tattoo Consent and Health Questionnaire Form
Please answer the following questions to the best of your ability. If a question does not apply to you, please type N/A.
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Company Name
Procedure/Service
*
Microblading
Powdered Ombré Brows
Lip Blushing
Body Art
Other
What is the date of your scheduled service?
*
-
Month
-
Day
Year
Date
Do you have a history of medication use or are you currently using medications including being prescribed antibiotics prior to dental or surgical procedures?
*
Yes
No
What are the medications you're currently taking and what is their purpose?
*
Are you currently on (within the last 2 months) any Retinol or Acne Medication products?
*
Acne Medication
Retinol
N/A
Do you have any allergies?
*
Yes
No
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies) if you do not have any, write: n/a
*
Are you currently pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Do you have any Botox or other injectables in the facial area?
*
Yes
No
Do you participate in outdoor recreational activities? Spend a lot of time in the sun?
*
Yes
No
Please check below if you have a personal history of or currently have the following medical condition:
*
Yes
No
Remarks
Cancer
Hyperpigmentation
Keloid
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Venereal Disease
Asthma
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia
Allergy to Latex
Cardiac valve disease
Other bleeding disorders
Do you have other risk factors for Blood Borne Pathogen exposure?
*
Yes
No
If yes, please explain.
*
Have you had any form of tattoo done before?
*
Yes
No
Have you recently been exposed to harsh sunlight or had a sunburn?
*
Yes
No
If applicable, approximately when did you have a sunburn?
-
Month
-
Day
Year
Date
In the best way that you can, please describe your skin type. (Oily, combination, dry, sensitive)
*
How did you hear about me?
Facebook
Instagram
Online Ads
Referral
Other
Acknowledgment
Please acknowledge the following:
*
I understand that this procedure cannot guarantee 100% expected results.
I allow Bailey Mora to take photographs for case review which is before and after.
I allow Bailey Mora to use these photographs for a marketing campaign or advertising.
I release the Bailey Mora for any liabilities related to the treatment and results.
I understand that this is a permanent tattoo procedure.
I confirm that a healing period of 6-8 weeks (varying per person) is required before the next or before the touch-up treatment.
I understand that this procedure might be painful and requires patience.
I understand that there might be an allergic reaction even if an allergy patch test is done 24 hours prior to the appointment.
I understand that I might experience infection, minor bleeding, swelling, and redness.
I accept the responsibility for determining the color, shape, and position for the enhancement as agreed during the consultation period.
I am aware that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware that an allergic response to pigment is rare and accept all responsibility if an allergic response occurs.
I am aware that a sensitivity reaction to anesthetics can occur and accept all responsibility if an allergic response occurs.
I fully understand and accept that non-toxic pigments are used during the procedure and that the tattoo enhancement achieved may fade over the course of 1-3 years. Even though the color has faded, the pigment will stay in the skin indefinitely and may leave a slight residue of color.
I understand that dyes, inks, and pigments are not approved by the Federal Food and Drug Administration and health effects are unknown.
I accept that the highest standards of hygiene are met, and that sterile disposable needles are used for each individual client, procedure, and visit.
I understand and accept that each procedure can be a process requiring multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I may need to return for a touch up procedure in the future.
I understand that the touch up procedure, if required, will be performed 6-8 weeks after the initial procedure and that after the 8 week period, I will be charged an additional fee for any procedures. I will book the appointment when it is convenient for both parties.
I understand that cosmetic enhancement is an invasive procedure and can be uncomfortable.
I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-2 days dependent on lifestyle. In some cases bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited for up to two weeks following the infusion process.
I am aware that the result of the procedure is determined by the following: Medication - Skin Characteristics - i.e. dry/oily/sun-damaged - Natural skin undertones -Alcohol intake and smoking - General stress - A compromised immune system - Poor diet - Post procedure care treatment.
I understand that immediately after the procedure the enhancement can be 40% to 60% darker than the desired result and can take between 4-10 days to lighten. I understand that the true color will be visible 1 month after each application, and that the color may vary according to skin tones, skin type, age and skin conditions. I appreciate that some skins accept color more readily than others and no guarantee of an exact effect or color can be given.
I agree to inform my Doctor of my tattoo if needed.
I agree to follow all pre-procedure and post-procedure instructions. I understand that infection and possibly scarring can occur if I do not adhere to said instructions.
To my knowledge, I do not have any physical, mental, or medical impairment or disability that my affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years of age. I am not under the influence of drugs or alcohol.
I hereby authorize, Bailey mora, to perform upon myself tattoo/ cosmetic body art enhancement. If any unforeseen condition arises in the course of the procedure(s), I further request and authorize her to use her full judgement and do whatever she deems advisable and necessary in the circumstances.
Signature
Date
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Month
-
Day
Year
Date
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