Cosmetic Tattoo Client Intake Form

Cosmetic Tattoo Client Intake Form

Permanent Makeup Client Intake Form
Today's Date

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Date
Client Information
Full Name *

First NameLast Name
Birthdate*

MonthDayYear
Date
Email*
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Phone Number *
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Media Handle
@example
Emergency Contact Full Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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TERMS AND CONDITIONS
It is my (the clients') responsibility to disclose any allergies or diseases.

I agree to release the permenant makeup artist from liability for any skin complications due to allergic reactions.

I understand that I will be in direct contact with various products topically applied.

I am aware of the specific chemicals and/or cosmetics.

I understand and accept that the color choices and color results in all procedures are not an exact science.

I understand and accept that these procedures may fade in time and this fading can change the original color pigmentation.

I realize this is an elective cosmetic procedure and is not medically necessary.

It is explained to me that the following possibilities may occur: minor or temporary bleeding, bruising, redness or other discoloration; swelling, fading or loss of pigment.

I give my consent to make up artist to discuss with my physicians for medical information required for the safety of my procedures.

I am aware that if an infection occurs after I have had this procedure to see with my primary physician or an emergency room, immediately.
Client Signature

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