Loading...


Permanent Makeup & Tattoo Client Consent Form







 

Permanent Makeup & Tattoo Client Consent Form

*Please read the terms and conditions of this agreement fully and carefully.

  • I hereby declare that I am of 18 years of age or older and have valid proof of age.
  • I am not under the influence of drugs or alcohol. I am competent to sign this agreement and am voluntarily submitting to getting permanent makeup.
  • I acknowledge that it is not reasonably possible for the practitioner to determine whether I may have an allergic reaction to the pigment/tattoo. The sensitivity test does not guarantee that I will not have an allergic reaction. I am aware that an allergic response is possible and accept all responsibility if one shall occur. I am aware that the pigment used meet EU and FDA standards.
  • I acknowledge that a sensitivity reaction to the anesthetics can occur and accept all responsibility if one shall occur.
  • I have been fully informed of the inherent risks associated with the procedure. I fully understand the risks, known or unknown, including but not limited to localized infection, swelling, bruising, allergic reaction to pigment/latex gloves/or anesthetics, difficulties in detecting melanoma and scarring. I am aware that light swelling, redness and sometimes bruising may occur and should subside in 1-4 days. I still wish to continue with the procedure and accept all risks that may arise.
  • I do not have epilepsy, hemophilia, a heart condition, hepatitis, HIV/AIDS, and am not breast feeding or pregnant. If I take blood thinning or thyroid medications, have diabetes, or have recently undergone chemotherapy, my condition is well-managed and I have received medical clearance for this procedure from my treating physician. I do not have any other medical conditions that may interfere with the procedure or healing. I am not sick with the cold or flu. I am not the recipient of an organ or bone marrow transplant. If I have any doubts about any of the described above, I have disclosed the information to my practitioner and received written doctors’ permission to go ahead with the tattoo. I do not have a mental impairment that would affect my judgement in electing to have the tattoo.
  • I do not have any medical or skin conditions on the site including but not limiting to scar, keloid, acne, eczema, psoriasis, moles, rash or sunburn.
  • I acknowledge having Botox before or after the procedure may change the shape of the area and accept responsibility if those changes shall occur.
  • I have been off Accutane for a minimum of a year before the procedure. I have not plucked, waxed, tinted or threaded my brows for at least 48 hours. I accept that doing so may result in additional pigment to be deposited into the skin where it was not intended. I have been off Retinols for the last 30 days. I have not tanned or sunburned, by tanning beds or by sun, for the last 2 weeks.
  • I understand that permanent cosmetics can be permanent and that if I choose to have them removed it may be expensive, leave scars and will not likely restore my skin to its exact appearance prior to getting tattooed. I understand permanent cosmetics is an advanced form of tattooing. I accept responsibility for the color, shape and position of the tattoo that was agreed to during the consultation.
  • I understand that the tattoo will darken within the first few days of the procedure. I understand that the healed result will be about 30-70% lighter than the initial result and it may take up to a month for the true healed color to show. I am aware that each initial procedure requires a 30-90 day touch up and annual touch ups thereafter. I am aware that after each procedure the chance of scar tissue may increase which will affect future retention.
  • I understand that my healed results are not guaranteed. I am aware that many factors including but not limited to my aftercare, use of certain beauty products, picking at the scab, sun exposure, medications, age, skin tones, skin conditions, bleeding during the procedure and oily skin can affect the healed result. I acknowledge that all skin types are different and some accept color more easily than others and no exact color can be given or guaranteed.
  • I am aware that lash enhancements may result in temporary loss of some eyelashes.
  • I am aware that having any lip procedures can bring on cold sores. It is up to me to consult with my doctor to determine the best pre and post treatment to limit the possibility of a Herpes outbreak. I acknowledge that if one shall occur it will affect my healed result and I assume all responsibility.
  • The aftercare instructions have been verbally explained to me and given to me in written form. I understand it is my responsibility to follow them until the tattoo is fully healed. I am aware scarring or other complications can arise if I do not follow the aftercare instructions.
  • I give my full consent to the tattoo being carried out by the practitioner.

 I hereby release and discharge to the fullest extent permitted by law, the practitioner and Exuvium Studios, from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my tattoo, whether caused by the negligence or fault of either the practitioner, Artistry By Kaysie / Exuvium Studios, or the facility.

I certify that I have read and fully understand the above consent form, I agree to be bound by it and choose to have Permanent Makeup/Tattooing of my own free will.

Date: October 4, 2024

 

Practitioner makes no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent makeup application and removal. These complications are usually mild and last only a few days. However, extreme complications are always possible. If you are healthy, not pregnant or nursing, have no previous tattoos and there are no visible reasons restricting you from receiving a tattoo, you must approve of the design and color before application of permanent makeup.

 

Informed Consent Form

Date: October 4, 2024

I have informed Kaysie Anderson / Artistry By Kaysie of any and all health conditions I may have prior to beginning the procedure.


                                                         

It has been explained to me that immediately after the procedure(s) is completed, the color will appear dark and the design will appear thicker and more solid. Within a short period of time (usually after 7-10 days) during the healing process, the color will lighten/soften and the design will heal thinner and less bold than it looked the day it was performed.  


 

I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), or scarring is a possibility as a result of my body’s reaction to the skin being broken during the procedure. I realize that my body is unique and that my technician cannot predict how my body will react as a result of this procedure. 


  

 

I am aware that after my initial procedure I will need to stay out of direct sunlight for 3-4 weeks. I am aware that even after it is healed and I choose to intentionally tan, including tanning beds, it will result in premature fading and can damage the skin. I fully understand that sun exposure will affect my retention. I understand that I cannot have chemical peels or lasers for 60 days after today’s procedure. I understand that if I do frequent peels or lasers, even if avoiding the forehead, my eyebrows may fade quicker and the color may shift or I can scar after my removal session. I understand that using products with Retinols, Retin-A’s and any other anti-aging creams or serums containing acids WILL fade my brows, freckles, and other permanent makeup prematurely, even after it is healed. I understand that such products above must be avoided entirely during the healing process. 


 

 

I understand that after the procedure the area may appear uneven, dry, itchy, tender, red, dark and irritated. This is all 100% normal. I also understand to not pick at my scabs as these symptoms are temporary and doing so can result in scaring or loss of pigment. I understand that color will fade and soften anywhere from 30%-70% or more. That at touch-up time we will adjust and fine tune any areas that has faded too much. At touch-up time we can also adjust color, shape and density. I understand healing is unique for every client. I realize that I will need a color boost every year to maintain its freshness. I understand that fading WILL happen after every procedure. I understand Kaysie Anderson/ Artistry By Kaysie has no control over my body’s healing process. 


 

 

REMOVAL: I understand that Kaysie Anderson / Exuvium Studios can not determine how many sessions it will take to remove all the pigment, how much pigment will come out during each procedure or predict how my body overall will react. Once pigment is removed it can show previous treatment scarring that was not done by Artistry By Kaysie / Exuvium Studios nor will I hold them accountable for scarring. I understand I have other options of removal and if I choose to get those done after Saline removal I must wait 8 weeks before a different treatment or I may damage the skin. 


  

 

I understand that I may still need to use makeup after my healed results. This procedure is intended as an enhancement to the natural features. At some point I will no longer be able to have my eyebrows Microbladed, since each procedure scar tissue is made. I understand that this is universal and the pigment will take less each time and in the future Ombre/Powder or Nano brow may be required. I understand if I have oily skin and/or large pores I am not a good candidate for Microblading. I understand that if I still choose to have permanent makeup done then my results can appear softer and fade quicker and I will require more frequent touch-ups. 


 

 

I have informed Kaysie Anderson / Exuvium Studios of any history of Cold Sores I may have. I understand even if I take Anti-Viral Medicine before my Lip Procedure I may still have an outbreak. If one was to occur during my healing my lips may not retain pigment. 


  

 

I understand that once I have had my initial procedure done by Kaysie Anderson / Artistry By Kaysie and I choose to go elsewhere for my touch-ups (or removal without consent) Kaysie Anderson / Artistry By Kaysie will no longer do future services on me. 


 

 

I understand and confirm, to the best of my knowledge, that the answers I have given are correct and that I have not withheld and pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Date: October 4, 2024

 

COVID-19:

In the last 14 days:

  • I have NOT been diagnosed with Covid-19, in contact with anyone who has or been contacted by a contact tracer or asked to self quarentine.
  • I have NOT had close conatct with anyone (within 6 feet for a cumulitive time of 15 minutes) with anyone displaying signs of Covid-19, waiting for test results or a known carrier.
  • I am not exeriencing chills, fever, loss of taste or smell, coughing, sneezing or any other symptoms related to Covid-19

Date: October 4, 2024

 

Authorization for photographs/videotaping

I authorize Kaysie Anderson / Exuvium Studios to take photographs preoperative and postoperative and/or video tape or by other similar means record my procedure(s). I understand that reproduction or publication of said photographs and recordings will be used for the purpose of educational/training documentation, research, before and after surgical portfolios, commercials, websites, advertisements and/or medical record documentation for my medical record. I understand that the photographs and recorded material will be used to demonstrate today's procedure(s) and that every effort will be mode to protect the patient's identity in those materials. I also understand I will not be compensated for any of the above material. 


Date: October 4, 2024

 

 





First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*

Phone*
Second Client's Date of Birth*
Second Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Third Client's Name

First Name*

Middle Name

Last Name*

Phone*
Third Client's Date of Birth*
Third Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Fourth Client's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Client's Date of Birth*
Fourth Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Fifth Client's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Client's Date of Birth*
Fifth Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Sixth Client's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Client's Date of Birth*
Sixth Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Seventh Client's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Client's Date of Birth*
Seventh Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Eighth Client's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Client's Date of Birth*
Eighth Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Ninth Client's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Client's Date of Birth*
Ninth Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Tenth Client's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Client's Date of Birth*
Tenth Client's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Chosen/Preferred First Name:
Pronouns Used:*
She/Her
He/Him
They/Them
Other
Check this box if you would prefer a "Quiet Appointment" without unnecessary small talk, if you are feeling anxious, drained, or would prefer to avoid conversation or have quiet time to relax for any reason. We will still discuss anything relevant to your procedure. There is never any judgment.
I would like a "Quiet Appointment"
Are you pregnant or nursing?*
No
Yes
Are you over the age of 18?*
No
Yes
Have you had aspirin or blood thinning products in the last 7 days?*
No
Yes
Have you had alcohol or caffeine within the last 24 hours?*
No
Yes
Have you had any mood altering drugs in the last 8 hours (Xanax, Prozac etc.)?*
No
Yes
Do you have a history of cold sores, herpes or fever blisters?*
No
Yes
Do you have problems with healing, scar easily or keloid?*
No
Yes
Do you bleed easily from minor injuries?*
No
Yes
Have had previous problems with tattoos or have been advised not to have one?*
No
Yes
Are you sensitive or allergic to latex?*
No
Yes
Have you had any permanent makeup or removal on the intended area before coming to Exuvium Studios (even if the previous work is no longer visible)?*
No
Yes
Are you allergic to metal? (as in non-gold jewelry)*
No
Yes
Are you required to take antibiotics before dental or invasive medical procedures?*
No
Yes
Do you take prescription drugs?*
No
Yes
Do you have any drug allergies? (Please list in space below)*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Do you intentionally tan by tanning beds or direct sun?*
No
Yes
Do you have Hepatitis, or have experienced Jaundice in the last year?*
No
Yes
Have you been diagnosed with HIV/AIDS?*
No
Yes

If you are checking YES to any of the boxes above, it does not indicate you are not an acceptable candidate for Permanent Cosmetics or Removal. It may simply be information that is valuable to your technician as each person's body is unique, or it may indicate that based on health conditions that affect healing, it would be advisable to consult with your physician before proceeding.


If this form has not addressed a medical condition you have please list it below.
Does your skin have problems healing?*
No
Yes
Do you have a history of skin diseases, remarkable sensitivities or allergies to medications or cosmetics?*
No
Yes

(If YES, Please explain below)
Are you currently under a Doctor's care (other than for primary routine care)?*
No
Yes

(If YES, Please explain below)

Please list any surgeries, health issues or medical procedures you have undergone in the last year:
Are you on Hormone Therapy?*
No
Yes
Have you had Chemical Peels, Microdermabrasion or resurfacing procedures?*
No
Yes
Within the last 30 days
Are you currently on Accutane, Retin A, Renovo or Adapalene?*
No
Yes
Have been off of for a year or more
If there is visible scarring in the procedure area or you are seeking reconstructive or scar camouflage tattooing, is the scarring in question healed by at least 1 year? If you have had laser removal, has it been at least 6 weeks since your last session?*
No
Yes
Are you taking thyroid or anti-anxiety medications?*
No
Yes

(If YES, Please explain below)
Do you currently take medication?*
No
Yes

(If YES, Please list all below)
Do you wear contacts?*
No
Yes
Have you ever had an eye surgeries including Lasik?*
No
Yes

(If YES, Please explain below)
Do you have a history of cold sores?*
No
Yes
If yes to above: Do you currently take antiviral medications for them?*
No
Yes

If you would like to be tagged in Instagram posts using your photos, please list your social media handle(s):

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any pertinent information that may be relevant to my treatment and will advise the staff of any health changes.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!