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  • Kintsugi Skin House

    Paramedical Tattoo & Restoration

    Your Skin, Restored with Intention

  • CLIENT INTAKE & INQUIRY FORM

  • 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:*
     - -
  • 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:
  • Please flag anything that applies:*

  • LOGISTICS & PREFERENCES

  • Preferred contact method:*

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  • ACKNOWLEDGMENT

  • 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*
     - -

  • 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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