Consultation and Appointment Form

Consultation Form

Thank you for taking the time to fill out your Consultation Form. This helps me to know if you're a great candidate for the treatments that I offer!
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
City and State
Email Address*
example@example.com
Photo(s) of the requested treatment area. I will only work on the areas shown. *

Cancelof
Are you OVER the age of 18?*

YESNO
Do you have any allergies (Any type)?*

YESNO
Are you sensitive to latex?*

YESNO
Do you have any problems with healing?*

YESNO
Are you prone to keloids?

YESNO
Have you had any previous problems with tattoos?*

YESNO
Are you currently undergoing radiation or chemotherapy?*

YESNO
Do you have AIDS, HIV, Hep B or C?

YesNo
Are you anemic or have a diabetic condition?*

YESNO
Are you allergic to topical antibiotics preparations or desensitizers?*

YESNO
Are you currently pregnant or nursing?*

YESNO
Please know that there's a $50 non-refundable booking fee to book your appointment. The booking fee does go towards your full balance. You will be sent a contract via email to authorize your debit/credit card to pay your booking fee. THE CONTRACT IS ONLY VALID FOR 72 HOURS. Additional requests for a new contract afterwards will accrue a $10 fee.*

I'm aware
I allow Erica Kane Aesthetics to message me via text, email, or direct message, in response to my consultation results.

I allow ALLONLY textONLY emailONLY direct message
Do you have any additional questions, or additional medical history I need to be aware of? I will be able to give you your answers to the questions, along with your quote!
Thank you again for taking the time out to fill in this form. Your $50 booking fee is what confirms your appointment date and time. Quotes are only valid 2 WEEKS. If you have ANY questions, please contact me at 615-623-5045. I really hope to see you soon!(:
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Consultation Form