COSMETIC TATTOO CLIENT HISTORY AND
CONSENT FORM
NAME…………………………………………………………………..DATE……………………………
ADDRESS……………………………………………………..……………………………… …………...
PHONE……………...…..………………….…….EMAIL…………………………………………………
Are you currently on any medication? Some medications may affect your healing
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□ Alcohol Consumption within 24hrs □ □ □ □ Currently on Blood Thinners □ Pregnancy □ Heart Palpitations □ Hepatitis □ Glaucoma □ Contact Lenses □ Lash Enhancement serum □ Collagen Injections/Filler □ I take Retin A medication
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□ Diabetes □ taking Aspirin F □ Any Blood Clotting Problems □ High Blood Pressure □ Facial Surgery within the Last 3 Months □ Dry Eyes □ Eye Disorders □ Ever had Cold Sores or Gerpes □ I take/ have taken Roaccutane medication in the last 6 months |
Please list ALL medicine taken in the last week ………………………………………………………………………………………………………………...
Skin Type: □ Normal □Oily □Dry □Combination?
Comments………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………….
Consent
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 at home care advice if not I may have 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 final result or adjustment.
I am aware that latex gloves may be used and consent to their use.
I have been given an aftercare sheet and have read it.
I am over 18 years of age CLIENT SIGNATURE pre-procedure (I
TattooArtist Yevgeniya Pastushkova
COST $................................................. VISIT…………………………………………….……..………
CLIENT SIGNATURE……………………………………………… (TO BE SIGNED BEFORE TREATMENT)
I am satisfied with the results obtained from this procedure I have been informed that color may vary as the skin heals I have been given aftercare instructions.
CLIENT SIGNATURE……………………………………………… (TO BE SIGNED AFTER TREATMENT)