Consultation

Name *

First Name

Last Name

Date of Birth *

Must be over 18 years old.

MM

DD

YYYY

Please check all the items that are applicable to you.

Diabetes (Requires Doctor's approval)

Blood Thinners

Taking Aspirin (Bleeding concerns)

High Blood Pressure

Blood Clotting Problems

Hepatitis A, B or C

Heart Palpitations

Lupus or Cancer (Requires Doctor's approval)

Taking Fish Oil (Do not take for 7 days prior)

Dry Eyes

Glaucoma (No Eye Tattooing)

Contact Lenses (Remove for Eye Tattooing)

Eye Disorders (Not suitable for Eyeliner Tattooing)

Lash or Brow Enhancement Serum (Stop use 4 weeks prior)

Cold Sores

Currently Using Retinol in your Skincare Routine

Collagen Injections/Filler in Lips

Botox or Filler in your Face in the past 2 weeks

Facial Surgery within the last 3 months

Coffee (Caffeine) *

Do you understand that Coffee within 6 hrs of your appointment can cause blood thinning. We may refuse your appointment, if you have had coffee/caffeine within 6hrs of your appointment.

I Understand.

Not Suitable for Permanent Tattooing *

You will be unsuitable for you appointment if you are currently Pregnant or Breastfeeding, suffering from Seizures. If you have had Alcohol within 24hrs of your appointment.

I Understand.

Consent, Privacy and Confidentiality Policy *

I acknowledge the information on this form is for the purpose of the therapist. I understand that tattooing is artistic in nature, and no results or expectations can be guaranteed. I consent to the uploading of this information to a cloud network and will be held in accordance with the Australian Privacy Principals Statement. I understand that this treatment is for cosmetic purposes only and that any medication may affect colour. My skin tone will also affect colour. No guarantees have been made to me regarding the results. I understand that a tattoo is a permanent change to my appearance and can only be removed by laser or surgical means. I understand that the removal process may lead to scarring or disfigurement, and can be costly. I understand that after receiving the tattoo, my skin may never be restored to its exact appearance prior to the tattoo. I am responsible for the “at home care” using only the aftercare advice sheet. I may have risk of infection or fading of pigments if not carried out fully. I will not hold the therapist responsible in the event of any damage and shall not be entitled to take action against her at Law or in Equity for such treatment. I consent to before and after photographs of this procedure which is at the therapist’s discretion. I cannot donate blood for 4 MONTHS from today. I consent to the use of Topical Anaesthetics containing Lidocaine and Epinephrine. I am aware that I may require a follow up visit in 1-2 months’ time to achieve the final result or adjustment, herein called Perfection Visit. I have been given an aftercare sheet. I am over 18 years of age. I have answered every question thoroughly and honestly and understand that withholding information or lying may have negative repercussions on the treatment and/or results.

I agree to the Consent, Privacy and Confidentiality Policy