Page 1 of 1
Cosmetic Tattoo Intake Forms
Your features, elevated. Every design is customized to your face shape, your natural expression and skin health.
Client Information
:
Name
*
DOB
*
Phone:
*
Email:
*
Service Selection:
*
Service Selection:
Appointment and Pricing Policy:
*
Appointment and Pricing Policy:
Includes 2 sessions only. A third session is additional cost. Both appointments should be done within 6 to 8 weeks apart for the best healing and retention.
Failure to return within 8 weeks of your first session, may incur additional costs as more supplies are needed to complete desired results.
Cancellation Policy:
*
Cancellation Policy:
Spa Therapy requires 48 hours notice for all cancellations. Late cancellations may incur fees as these sessions are sometimes over 90 minutes.
Medical History
*
List any conditions, (including auto-immune), medications, allergies.
Have you had any of the following: (Check all that apply)
*
Have you had any of the following: (Check all that apply)
Botox
Diabetes
Facial surgery
Drink alcohol
Tan by booth or sun
History of chemotherapy
Oily skin
Pregnant (Currently)
Cancer (explain below type of cancer and the year)
Difficulty numbing/dental procedures
Alergic to topical numbing
Use products with Retin A
Please explain any conditions checked above:
Risks Involved In Cosmetic Tattooing: (Check the last box)
*
Could include and not limited to:
Risks Involved In Cosmetic Tattooing: (Check the last box)
Skin Irritation
Pigment Variations
Cold Sore (lip blushing)
Corneal Abrasion (eyeliner)
I understand the risks involved
Aftercare Agreement:
*
Aftercare Agreement:
Failure to follow instructions may affect final results.
It's not often, but sometimes the skin will shed almost all pigment after the first appointment. This does not mean it will not take, it means your body rejected something new. It almost always retains pigment following the second appointment but in some cases a third session is needed. This third appointment is not included in the original cost.
*
It's not often, but sometimes the skin will shed almost all pigment after the first appointment. This does not mean it will not take, it means your body rejected something new. It almost always retains pigment following the second appointment but in some cases a third session is needed. This third appointment is not included in the original cost.
I agree to my procedure and I understand the risks. I'm ready!
I fully understand the procedure and give permission to Sandy and Spa Therapy to perform the service of pigment implantation and have informed her of allergies, health conditions and medications. I consent to the risks associated and that there are no guarantees made, as final results vary due to skin conditions, aftercare and possible underlying health conditions we are unaware of. There are no refunds for any reason.
*
I fully understand the procedure and give permission to Sandy and Spa Therapy to perform the service of pigment implantation and have informed her of allergies, health conditions and medications. I consent to the risks associated and that there are no guarantees made, as final results vary due to skin conditions, aftercare and possible underlying health conditions we are unaware of. There are no refunds for any reason.
I understand and consent
Today's Date:
*
Sign Here:
*
Signature
Submit
