Paramedical Camouflage Intake Form

Paramedical Camouflage Intake Form

for scar/stretch mark camouflage tattoos
First and last name*

First NameLast Name
Email address*
Phone number*
Format: (000) 000-0000.
Birthday*

MonthDayYear
Gender/preferred pronouns
Emergency contact*
Name, phone number, relation to you
Referred by:
If applicable
YesNoOther
YesNo
Please list them in detail.*
YesNo
Please list them in detail.*
TryingTrying soonPregnantBreastfeedingNone of the above
An active infectionALS or MSAnemia/Sickle CellAuto-immune DiseaseBlood clotting abnormalitiesBlood diseaseBotox or FillerCancerChemo or RadiationCold soresCosmetic tattoos before todayDiabetesEmotional or psychiatric illnessEmphesyma or Lung diseaseEpilepsy or other seizure disordersFear of blood or needlesFainting spellsHeart conditionsHemophiliaHepatitisHerpesHigh/low blood pressureHIV/AIDSHyper- or Hypo-pigmented scarsImmune system disorderIron deficiencyKeloid scarringLambert-Eaton SyndromeLiver diseaseMRI in the futureParkinson'sSensitive SkinSkin diseaseSkin lesionsSkin peelsStrokeTumor, growths, cystsVitiligoNone of the aboveOther
Please explain:*
AcutaneAspirinBlood thinnersGlycolic AcidHydroquinonePhotosensitizing MedicationsRetin-ARetinolValtrexVitamin EOther
Please explain. If there are others, please list them here:*
AcutaneAspirinBacitracinBactrobanBarbituratesBio OilBlood thinnersFood allergiesGlycolic AcidHydroquinoneIodineLatexLocal anesthetics (novocaine, lidocaine, epinephrine)MakeupMetalsMoisturizersMycitracinNeosporinPenicillin or other antibioticsPhotosensitizing MedicationsRetin-ARetinolRubbing alcoholSkin allergies (soap, cream...)Sulfa drugsValtrexVitamin ERubberVaselineOther
Please explain. If there are others, please list them here:*
Tell me all about your scar(s)/stretch mark(s): The more details the better.*
What happened, when it happened, where on your body, why it bothers you, how you take care of it, etc.
Please upload some photos/videos of the area. Make sure it's a very clear/focused photo, and done in good lighting (natural lighting is best!).*

Cancelof
Is there anything else I need to know? (No such thing as TMI!)
YesNo
If you'll allow me to tag you in my Instagram posts, please provide your handle below:
I acknowledge that any information contributed by me is true to the best of my knowledge, and that the present condition of the area that has been treated or will be treated is stated on this record.

I fully understand that Parrell Ink only provides beauty services; there is no medical treatment involved. I realize that with any beauty service there may be certain risks which must be understood. I will be fully responsible for any and all results which may arise from these beauty services.

I do hereby agree to hold Sasha Parrell and Parrell Ink and their affiliates and agents free from any and all claims or suits for damage, for injuries or complications resulting from any beauty service provided by Parrell Ink. The nature and purpose of the beauty services, the risks involved and the possibility of complications have been fully explained to me.

I understand that no guarantee or assurance has been given by anyone as to the results that may be obtained. I consent to receive emails from Parrell Ink and grant Parrell Ink permission to use my photos.

*NO REFUNDS

*NO GUARANTEES

By signing and submitting this form I acknowledge that I have read and understand the above and all of my questions have been answered and that I consent to have services provided by Parrell Ink in accordance with these terms and conditions.
Sign Below:*
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