Tattoo Client consultation form Date(Required) DD slash MM slash YYYY First Name(Required) First Last Name(Required) First Date of Birth(Required) DD slash MM slash YYYY Phone(Required)Email(Required) Your Address(Required) Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Occupation How did you hear about us?(Required)Internet searchGift VoucherLetter BoxReferredWalk byGumtreeCudo/DealsYellow PagesGrouponOtherWould you like to be informed of our specials?(Required)(Please ensure you have clearly supplied your email id & contact no. above) Yes No Are you currently on any medication? Some medications may affect your healing and colour outcome. These include medications for HRT, depression, diabetes and immune diseases. Please list ALL medicine taken in the last week Please tick any of the following that may apply to you.(Required) Alcohol Consumption Currently on Blood Thinners Pregnancy Heart Palpitations Hepatitis Glaucoma Contact Lenses Lash Enhancement serum Collagen Injections/Filler I take Retin A medication Diabetes Taking Aspirin Any Blood Clotting Problems High Blood Pressure Facial Surgery within the Last 3 Months Dry Eyes Eye Disorders Ever had Cold Sores I take/ have taken Roaccutane medication in the last 6 months None of above Skin Type(Required) Normal Oily Dry Combination CommentsConsentInitial(Required) I understand that this treatment is for cosmetic purposes only. That no guarantee has been made to me regarding the results as I understand that every skin responds differently. I am responsible for the “at-home care” using only the aftercare product in my home care advice if not I may have the risk of infection or fading of pigments if not carried out fully. Initial(Required) I consent to before and after photographs of this procedure, which is at the Therapist’s discretion, I cannot donate blood for 3 MONTHS from today I consent to the use of Topical Anaesthetics containing Lidocaine, & Epinephrine. I am aware that I may require a follow-up visit in 1-2 months’ time to achieve the result or adjustment. I am aware that latex gloves may be used and consent to their use. Initial(Required) I have been read properly in the consultation form and I am over 18 years of age. I understand that this treatment is for cosmetic purposes only. That no guarantee has been made to me regarding the results as I understand that every skin responds differently. I am responsible for the “at-home care” using only the aftercare product in my home care advice if not I may have the risk of infection or fading of pigments if not carried out fully. I consent to before and after photographs of this procedure, which is at the Therapist’s discretion, I cannot donate blood for 6TH MONTHS from today I consent to the use of Topical Anaesthetics containing Lidocaine, & Epinephrine. I am aware that I may require a follow-up visit in 1-2 months’ time to achieve the result or adjustment. I am aware that latex gloves may be used and consent to their use. I have been explained aftercare and read properly in the consultation form and I am over 18 years of age.CLIENT SIGNATUREpre-procedure (I agree to the above) STATEMENT OF CONSENT AND RECITALSPlease read and tick all lines(Required) Aftercare instructions have been explained to me and to retain in my possession, which I will follow to the best of my ability. If I have questions, I will contact you. I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur. I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the colour. I understand that sun, tanning beds, pools, some skin care products, and medications can affect my permanent makeup. I will tell all skincare professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI. I accept the responsibility for explaining to you my desire for specific colours, shapes, and positions for any procedure done today. I understand the feather and colour will be lighter as per time and according to skin absorption and reflection. I understand that implanted pigment colour can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the colour with future applications and a touch-up session within 30 days to 60 days. I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as infection, misplaced pigment, poor colour retention and hyper-pigmentation. I authorise the taking of photographs and video footage which will be retained as a private record for the clinic and practitioner. I ALSO CONSENT TO THE USE OF MY PHOTOGRAPHS AND VIDEO FOOTAGE FREE OF CHARGE FOR MARKETING PURPOSES. YES NO Certify(Required) I certify that I have read or have read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize. __Macy__, as my Eyebrows or eyeliner, Lip tattoo Embroidery technician to perform on my body the procedure desired today. After Care InstructionFirst, (If skin swelling)1-2 days apply icepack for 20 mins twice a day. Apply antibiotic ointment or vaseline- petroleum jelly which contains a moisturiser morning and night (preferably before a shower as the area should not be wet until healed). Do not rub, scratch, or pick at the scabs that form as the pigment will be removed before it has healed into the skin. Healing should be complete in 7-14 days. Avoid sun and swimming in pools, rivers, and hot sauna for 2 weeks. Eyeliner procedure: You should also rinse your eyes with eyewash and clean around the eye area with damp cotton wool to remove any excess ink that may remain. Do this morning and night. No foundation makeup should be placed on the tattooed area for 2 weeks. You may need to take a pain killer for a few days. This should be prearranged with your doctor.Initial(Required) I am satisfied with the information obtained from this procedure I have been informed that colour may vary as the skin heals, and I have been explained aftercare instructions. CLIENT SIGNATURE(Required)Therapist ColumnNEEDLE SIZE PROCEDURES COLOURS FOLLOW-UP VISIT COMMENTSSpecialist SIGNATURE(Required) Δ
