Tattoo studios generate online tattoo release forms for customers to fill out online.
Permanent Cosmetics &
MicroPigmentation Intake/
Client Consent
Please fill your name:
*
Please enter your full name.
Date of Birth:
*
Please enter valid date.
Please Enter Date
*
Set Today
Please enter valid date.
Please fill in Address:
*
Please enter address.
Phone number:
*
Please enter your phone number.
Email:
*
Please enter your email.
Service Type/Area of Treatment:
*
Please enter your answer here.
How did you hear about us?
*
Please enter your answer here.
Do you currently have or previously have had any of the following:
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MRSA
Diabetes
Hepatitis (A,B,C,D)
Blood Disorder(s)
Abnormal Heart Condition
Autoimmune Disorder
Difficulty Numbing with Dental Work
Alcoholism
Pregnant/Breast Feeding Now
Forehead/Brow and/or Face Lift (within the past 12 months)
BOTOX (within 8 weeks)
Chemical Peel (within 4 weeks)
Brow or Lash Tinting (within 2 weeks)
Chemotherapy/Radiation (within 12 months)
Accutane (within 12 months)
Oily Skin
Sun Exposure (Includes artificial)
Take Medications After Dental Work
Blood Thinners (Aspirin, Ibuprofen, Coumadin etc.)
Allergic Reaction to Medications (Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzoyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.)
Keloidal Scarring (Keloids: Raised/Uneven Scarring; Over-Growth of Scar Tissue)
Hyperpigmentation (Patches Of Skin Darker In Color Then Surrounding Tissue)
Please select at least one choice above.
Please disclose of any/all disorders, diseases and/or medical conditions.
*
Please enter your answer here.
Please list all OTC & prescription medications and/or supplements you are currently taking.
*
Please enter your answer here.
Please list any/all products containing Retinol, Glycolic Acid and/or Alpha Hydroxyl within your regular skin care regimen.
*
Please enter your answer here.
Initial Here
I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.
*
Please click the yellow area and provide your initials here.
Initial Here
I understand that Retin A, Retinol, Alpha Hydroxy and Glycolic Acids must NOT be used on the treated area(s) at any point. They will alter the color of the tattooed area.
*
Please click the yellow area and provide your initials here.
Initial Here
I understand that sun, tanning beds, pools, some skin care products and medications can have negative effects on my permanent makeup.
*
Please click the yellow area and provide your initials here.
Initial Here
I understand that successful color saturation CANNOT be guaranteed due to undetected or hidden scar tissue.
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Please click the yellow area and provide your initials here.
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I agree and accept responsibility to inform all skin care professionals or medical personnel about my permanent makeup procedures, especially before undergoing an MRI scan.
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Please click the yellow area and provide your initials here.
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I accept the responsibility to explain to my technician any desires for specific color, shape, and/or position for any procedure done today. I understand & accept that my technician has the right to refuse my procedure if we are not able to agree on the final shape, color and/or positioning that I am requesting & that she feels will be most suitable to deliver the most natural yet enhanced results.
*
Please click the yellow area and provide your initials here.
Initial Here
I understand that implanted pigment color may change or fade over time due to circumstances beyond control and that I will need to maintain the color with future applications and an initial standard touch up session (also referred to as the “perfecting session”) at 60 days/8 weeks.
*
Please click the yellow area and provide your initials here.
Initial Here
I acknowledge that the proposed procedure(s) involve risks inherent in the process and have the possibilities of complications during and/or following the procedures such as infection, misplacement, patchy and/or faded pigmentation, poor color retention and hypo/hyper-pigmentation.
*
Please click the yellow area and provide your initials here.
Initial Here
I agree ...
*
Please click the yellow area and provide your initials here.
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