Appointment Request Form
This is a digital consultation form to determine if you are a candidate for the requested procedure. Upon assessing your suitability, you will be provided with the option to schedule either an in-person consultation or the actual treatment.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Who/what social media platform were you referred by?
*
Phiacademy Craft Master Carla Goycochea services by referral only.
Are you 18 y/o or older?
*
Please Select
Yes
No
Reason for getting Areola Tattoo?
*
Please Select
Breast Surgery
Fix Symmetry and Coloring
Rebuild/Fix Areola due to accident/life event
If you had breast surgery, what type?
*
Please Select
Mastectomy
Double Mastectomy
Lumpectomy
Reduction
Augmentation
Lift
Reconstruction
When was the last surgery?
Were implants used? If yes, what type?
*
Please Select
Silicone
Saline
Have you had nipple reconstruction surgery?
*
Please Select
Yes
No
Are there any ongoing follow-up treatments or medical restrictions?
*
Please Select
Yes
No
Have you had any previous tattooing (medical or decorative)? If yes, how did your body heal?
*
Please Select
Yes
No
If yes, please state the type of of tattoo and how did your body heal?
PLEASE SUBMIT 2 CLEAR PHOTOS OF YOUR BREASTS FRONT AND SIDE
*
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Please specifically describe what you would like to enhance with Areola Tattoo?
*
Are you willing to wear the treated area darker than desired result for about one week?
*
Please Select
Yes
No
Do you use tanning beds often?
*
Please Select
Yes
No
Are you currently pregnant or nursing?
*
Please Select
Yes
No
Do you smoke or consume alcohol regularly?
*
Please Select
Yes
No
Do you understand that any tattoo procedure requires at least two to three sessions to achieve desired results?
*
Please Select
Yes
No
Do agree to follow the main aftercare recommendations of avoiding: sun, pool, ocean, sauna and other invasive treatments for the first week?
*
Please Select
Yes
No
Do you agree to following Craft Master Carla's recommendations on the amount of sessions needed to accomplish desired results based on skin type and color?
*
Please Select
Yes
No
Do you agree to providing images as requested so that Craft Master Carla can provide a digital design of the style that would suit you best?
*
Please Select
Yes
No
Do you agree to this establishment 's No-Refund policy as desired result is previously approved following digital design?
*
Please Select
Yes
No
Please disclose all medical conditions, if applicable.
*
I understand that I will submit a “Physician clearance confirmation” signed by my doctor, surgeon, oncologist, etc. that confirms I am medically cleared and safe to undergo this particular procedure.
I Agree
I understand that it will take from 24-72 hours to receive a response and/or digital design of the service requested and I hereby certify that all the information provided above is true and accurate.
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