• CLIENT INTAKE & INQUIRY FORM

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  • Kintsugi Skin House

    Paramedical Tattoo & Restoration

    Your Skin, Restored with Intention

  • Welcome to Kintsugi Skin House.

    Thank you for trusting us with your restoration journey. Please take a few quiet moments to complete this form. Every answer you share helps us design a treatment plan that honors your story and your skin. All information is kept strictly confidential.

  • PERSONAL INFORMATION

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • WHAT BRINGS YOU TO KINTSUGI SKIN HOUSE

    This gives us more insight.
  • Please check each service you are inquiring about:
  • Services*

  • YOUR STORY

    Sharing your story helps us honor it and meet you where you are.
  • Are you fully healed?*

  • QUICK HEALTH SCREEN

  • A full medical history is completed at your consultation. For now, please flag anything that applies:
  • Checking a box here does not disqualify you. It simply helps us plan safely for the best experience.
  • Please flag anything that applies:*

  • LOGISTICS & PREFERENCES

  • Preferred contact method:*

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  • Upload clear photos of the area you'd like treated. These images are viewed only by your Kintsugi technician and are used solely to assess candidacy and prepare for your consultation. Photos are handled with full confidentiality and deleted upon request at any time. *

  • ACKNOWLEDGMENT

  • I confirm I am 18 years of age or older.*

  • I confirm the information above is true and complete to the best of my knowledge.

    I understand that Kintsugi Skin House will use this information solely to determine candidacy and to prepare a personalized in depth consultation.

    I understand that submitting this form is an inquiry, not a booking. I understand that a Comprehensive Consultation and patch test are required before any treatment is scheduled.

  • ACKNOWLEDGMENT & SIGNATURE

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Thank you for beginning your Kintsugi journey with us. Within two business days we will reach out to schedule your consultation.

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