Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Gender

Female

Male

Prefer not to say

Are you diabetic?

Yes

No

Heart Issues?

Yes

No

Hepatitis?

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Allergies?

Yes

No

Are you currently taking any acne medication?

Yes

No

Botox?

Yes

No

Are you currently using any products with Retin-A or Alpha Hydroxy (AHAs)?

Yes

No

Do you have an Autoimmune Disease?

Yes

No

Are you prone to Keloid scarring?

Yes

No

Problems with healing?

Yes

No

Have you been treated with Chemotherapy or Radiation in the last 12 months?

Yes

No

Topical anesthetic is used during the appointment. These anesthetics contain Lidocaine, and Epinephrine. Do you give approval for these topicals to be used during your appointment?

These products provide relief from any pain or discomfort that could occur during the tattoo session.

Yes

No

Have you had cosmetic tattooing before?

Yes

No