Permanent Makeup and Body Art Client Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Gender

Pronouns

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please upload a photo of the front of your ID as required by the PA Health Department.

How did you learn about us?

Service Type; Select all you are inquiring

I understand that there is a $50.00 non refundable security deposit for all services to secure my appointment. This deposit goes towards the final amount due at end of service.

I consent to a $50.00 deposit to secure my appointment.

SKIP IF NOT BOOKING PERMANENT MAKEUP

Please list your natural hair color, dyed color if you dye your hair, and eye color.

What is your skin color and complexion like? (Super fair, olive, tan, brown, etc.) (Reddish, patchy, splotchy, etc.)

Please select which option applies to you.

Anything else you'd like me to know about your skin?

SKIP IF NOT BOOKING FOR BROWS

Have you ever had your eyebrows tatted or micro bladed? If you have ever had your eyebrows done by someone other than The Inked Lady you must send photos to theinkedladyllc@gmail.com for clearance.

If you have previous brow work done by The Inked Lady please upload photo of brows in good lighting here.

By signing you agree as follows: I understand I will be turned away and forfeit my deposit if I did not let The Inked Lady know of my previous work within a week of booking my appointment, as stated in the confirmation email I received upon booking. If The Inked Lady hasn't cleared my photos prior to filling out the paperwork, I understand that I may be turned away and lose my deposit. I understand that if The Inked Lady cleared my brows to have an appointment, there is a risk the brows will not heal properly due to previous ink and possible scar tissue from my original artist. I understand the service is non-refundable and I will not receive a free touchup to address any issues I may see after healing. I understand that The Inked Lady is not responsible for any inconsistencies after having a touch up over previous work, and that there may be no visible difference in my brows after the service. I agree to all of the above and fully understand the risks involved with my service.

SKIP IF NOT BOOKING FOR BROWS

Tell me what you would like for your future brows ( filled in, thick, fluffy, dark, hair strokes, bold, etc.)

Tell me what you do like about your eyebrows now and what you don't like about them.

Please add clear photo of clean bare brows with no makeup and in good lighting .

Please add clear photo of your brows with makeup if you wear any on them.

Please add inspiration photo if you have any.

SKIP IF NOT BOOKING FOR FRECKLES

Tell me if you want light, medium, or full coverage freckles and if you want to add any beauty marks (moles, stars, hearts, etc.)

Please add clear photo of your face with no makeup in good lighting.

Please add inspiration photo if you have any.

SKIP IF NOT BOOKING FOR TATTOOS

Your tattoo idea in your own words. If you have questions reach out through call, message, or email.

Please add inspiration photo if you have any.

Tattoo from a The Inked Lady flash sheet. Please specify name of sheet and number.

Please add photo of which flash you want.

MANDATORY FOR ALL CLIENTS

Please answer the following question with full honesty and accuracy.

Please list all skincare products you’ve used in the past 30 days if booking permanent makeup.

Please list any medical conditions including communicable diseases, prescriptions and supplements taken in the past month.

Do you have any known allergies or adverse reactions to dyes, pigments, latex, iodine, or other such products?

If yes, what are your allergies?

Are you allergic to epinephrine or any other topical numbing agents?

Have you ingested any anticoagulants (warfarin, heparin, eliquis, etc.) within the last week before your scheduled appointment. If so you must reschedule your appointment.

Have you ingested any non steroidal anti-inflammatory NSAIDs (ib profen, acetaminophen, naproxen, etc.) in the last 24 hr before your scheduled appointment. If so you must reschedule your appointment.

Have you ingested any antiplatelet drugs (aspirin, clopidogrel, etc.) in the last 24 hr before your scheduled appointment. If so you must reschedule your appointment.

Have you taken any antibiotics within 10 days of your scheduled appointment? If so you must reschedule your appointment.

Have you had any botox treatments to your forehead within 10 days of your scheduled appointment? If so you must reschedule your appointment.

Have you ingested any medication that can inhibit the ability to heal a skin wound?

Do you have a history of skin diseases that might inhibit the healing of the body art procedure?

Have you been diagnosed with hepatitis or jaundice in the past 12 months?

Are you under the influence of drugs or alcohol?

Have you had alcohol in the last 24 hr? If yes you must reschedule for best healed results.

Have you had caffeine in the last 12hr? If yes you must reschedule for best healed results.

Have you eaten in the past 4 hours before scheduled appointment? Please eat within 4 hours before your appointment.

Please list all allergies, medical conditions, supplements, and prescriptions used.

Please check off all that may apply to you. If you check any off, you are not applicable for these services unless you have a written response from a healthcare professional or you’ve consented regardless of health issue.

I value each and every one of my clients, and I want to ensure that everyone has a positive experience when working with me. That is why I have established policies that are designed to protect both, my clients and my business. By reading and agreeing to these polices when booking your appointment, you can feel confident that you are making an informed decision when choosing to work with me.

thank you for you interest in booking with me.

1. All appointments must be canceled within a 24 hour notice to avoid any additional charges. All appointments canceled with less than a 24 hours will be charged 50% of the remaining cost of the scheduled service(s) that day.

2. No call no shows will be charged 100% of the price for scheduled service(s) that day, and will not have the option to book again.

3. If you are more than 10 minutes late to your appointment I will need to reschedule your appointment and charge a cancellation fee of 50% of the scheduled service(s) price.

Signature

I acknowledge that I have been given full opourtunity to ask any questions which I may have. I also acknowledge that all my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the fact of the matters set below, and I agree as follows.

The Inked Lady makes no attempt , or claim to, practice medicine. Some individuals will have complications related to permanent makeup application. The severity of these compilications may vary. By signing below, you agree to understanding the risks related to having the service performed and consent to receiving the service. This includes all services provided by The Inked Lady such as Nanobrows, Faux Freckles, and all body art/tattoos. These risks include, but are not limited to: allergic reactions, premature fading/spreading/migration of ink, discoloration of ink - especially in the event that aftercare instructions are not followed. Body art and permanent makeup can cause swelling, bruising, discomfort, bleeding, pain, allergic reactions, irreversible changes to the body, has a risk of infection, and may leave permanent scarring and disfiguring.

I acknowledge that it is not reasonably possible to determine whether I may have an allergic reaction to any of the inks, topical preperations, or processes in the procedure. I agree to accept the risk that such a reaction is possible. I have informed the artist of any existing allergies, medical conditions, and prescribed medications.

Signature

I acknowledge that complications are always possible as a result of the permanent makeup procedure, particularly in the event where post procedural instructions are not followed. I realize that my body is unique and the artist cannot predict how my skin may react as a result of the procedure. I acknowledge that the procedure will result in permanent change to my appearence and that no representations have been made to me as the ability to later change or remove the result. I understand that future lasor treatments or other skin altering services or products may alter or degrade by permanent makeup. I understand that such changes are not the fault of the practitioner I further understand that such changes may not be correctable through future permanent makeup or removal. I acknowledge that obtaining permanent makeup services is by my choice alone, and I consent to the application of the procedure and its risks, and to any conduct or actions of the practitioner reasonably necessary to perform the procedure. Tattoos should be considered permanent; that it can only be removed with surgical or invasive procedure; and that any effective removal may leave permanent scarring and disfigurment.

Signature

I understand that some tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. I further understand that all cosmetic permanent makeup and tattooing services is permanent , and no promises have been made in the ability to remove or alter the results.

I have been given the full opourtunity to share any concerns or questions regarding the shape of the mapping and color to be used for the service and consent to recieving the service and have approved both the shape and the color of ink to be used. I have been given full oppourtunity to choose and consent to the body art I've been given regardless of results.

By signing below I am consenting to any and all services I have booked with The Inked Lady LLC and I understand The Inked Lady LLC is not responsible for any issues during or after the procedure and will not be held responsible for removals, free touchups.

I understand permanent makeup and tattoos are permanent.

I understand that The Inked Lady has every right to cancel an appointment at any time including during appointment due to noncompliance during procedure, harrassment, etc.

I give The Inked Lady LLC permission to use photos of my tattoos and permanent makeup on social media, ads, and website platforms.

Signature

Please read all the sentences and sign the agreement.

I authorized The Inked Lady to perform a cosmetic enhancement/ tattooing upon me on this day.
I was informed that permanent and semi-permanent cosmetic enhancement is the same as the process of tattoo and it is an advanced version of it.
I completely understand that in some rare cases, allergic reactions may occur even after my disclosure of all known allergy history I may have due to the pigment. I accept all the responsibility, and I fully understand the health risk of it.
I accept that the pigment might fade before or after 3 years, and may leave a mark or residue of color.
I understand the possible side effects of the procedure and will be able to diagnose if it is normal or not.
I confirm that I do not have any physical, medical, and mental conditions that might get conflict with the procedure.
I confirm that I have read the before booking page on The Inked Lady's website to ensure I am eligible for these services.
I confirm that I have had the opportunity to ask questions about the services provided and I was given satisfactory answers.
I confirm that I will strictly follow the pre and post-procedure instructions given to me.
I confirm that all information I entered in this form is accurate and true to the best of my knowledge.
I hereby certify and give The Inked Lady LLC my full consent to perform the necessary procedure. By signing below, I confirm that I have read and understood the statements above.

Date Signed

Date

Signature

My Products

$50 deposit

Goes towards your appointment.

$50.00 Quantity

Total

Credit Card