Permanent Cosmetics Release

1
First things first let's confirm who you are.
2
Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Date* This field is required.
Date
Month
Day
Year
5
I am here for ( service you are receiving ) blanks * . The Artist providing my service today is Type a label *
6
in the rare case of an emergency during todays session, who should we contact on your behalf? Name / relation / phone number* This field is required.
7
Referrals are the BIGGEST compliment. did anyone refer you? we'd love to thank them.
8
please select any that apply to you
9
Do you have ANY allergies or sensitivities?* This field is required.
10
Date of last Botox or Filler Treatment* This field is required.
11
Fill us in on any skincare you are using or have been using in the last 60 days. please include any professional or at home treatments.* This field is required.
12
Have you ever used prescribed skincare?* This field is required.
13
When was the last time you took OTC painkillers? ( Advil, ibuprofen ect. )* This field is required.
14
Tell us any prescribed medication or any supplements you are currently on or have been on in the last month.* This field is required.
15
When was the last time you had caffeine? * This field is required.
16
Are you feeling social today? please don't Hesitate to let us know if your like a silent appointment today.* This field is required.
Please Select
Please Select
Let's get to chatting!
This is "me time", I'd prefer a quieter appt today.
17
Is there anything we can get you before we get started?
Something to Drink
A Snack would be great
Something to snack on and something to drink
18
At the end of your tattooing session, a ten minute red light therapy session will be done to help speed up your healing process once you leave. It’s completely painless and During this session you’ll get a little bit of “you” time. Let me know what your comfort level is. ( PLEASE SKIP IF THIS IS YOUR 8 WEEK TOUCH UP)
Give me all the pampering! ( Scalp and neck massage complimentary )
I would prefer ten minutes to myself without a massage
I would like to skip the RLT today.
19
anything else you'd feel we should know before we get started?
20
* This field is required.
21
Sign and Submit once you are all finished!
Powered by Jotform SignClear
Should be Empty: