Client History Form Release Form
Let us do this part
Today's Date:
Thu Oct 18 2018 02:25
Artist:*
Client History Profile Form
Please read & answer
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Are you pregnant or nursing?
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Have you had any alcohol in the last 24 hours? (Prior to the actual appointment as alcohol thins the blood and hinders healing) PLEASE AVOID ALCOHOL FOR 48 HOURS TO ACHIEVE BEST RESULTS.
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Have you ever had any cold sores or fever blisters?
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Do you have allergies to latex?
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Have you had a laser or chemical peel within 6 months?
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Have you ever had any permanent cosmetics or tattoos applied? Please describe where on your face/body and approximate date.
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Do you bruise easily?
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Do you routinely use Retin-A, glycolic, or other exfoliating products? These will fade your tattoo prematurely.
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Do you wear contact lenses? IF HAVING EYELINER PROCEDURE PLEASE BRING GLASSES TO WEAR AS CONTACTS TO BE WORN ONLY AFTER HEALING
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Are you allergic or sensitive to any metals, for instance, metals used for jewellery?
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Do you have any problems healing from small wounds?
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Do you use any Lash growth serums? If you are having an eyeliner tattoo, you need to stop this for 4 weeks prior to your appointment.
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Do you use tobacco? If you use tobacco you may heal slower and this affects the timing on scheduling a touch up appointment if applicable.
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Do you have any heart conditions? Mitral Valve Implants, palpitations,
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Are you a diabetic? If so Type 1 or Type II?
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Do you have any auto immune disorders?
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Are you sensitive or allergic to hand creams or body lotions?
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Do you have your lips injected with filler materials? For lip tattoo procedures you will need to wait before getting a tattoo.
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Do you menstruate and if so when is your next cycle? You may be more sensitive to pain.
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Do you hyperpigment? (Tendency to develop dark spots on the skin from the sun or wounds)
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Do you tend to develop keloid or hypertrophy scars?
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Do you scar easily from minor skin injuries?
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Do you have seizure related conditions?
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Do you have a tendency to faint or become dizzy?
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Do you bleed excessively from minor cuts?
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Do you have prosthetic implants?
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Do you consume aspirin, Omega Fish oils or Ibuprofen or Tumeric daily?
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Are you under treatment for depression?
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Are you sensitive to petroleum based products?
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Do you have Botox injections? If so when was the last procedure and where on the face?
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If you have permanent cosmetics or tattoos did you have any problems with healing after they were applied?
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Are you undergoing radiation or chemotherapy treatment?
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Are you now or have you ever been on the acne treatment Accutane? (Roaccutane) You will need to wait for one year before getting a tattoo.
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Are you wearing a pacemaker?
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Do you take prescription drugs? What are you currently taking or have taken in the last month?
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Are you anaemic?
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Do you have a history of skin sensitivities?
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Do you have any medical condition that has resulted in a medical professional requiring you to premedicate with an antibiotic prior to a dental or other invasive procedure?
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Do you have allergies to topical makeup?
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Do you have dry eyes?
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Do you intentionally tan - direct sun or tanning bed?
This will fade your tattoo prematurely.

If you are currently tanned, please wait until the tan has faded for your new tattoo.
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Do you personally have any history of cancer?
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Do you have a history of stroke or heart attack?
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Do you have problems being anesthetised for a dental procedure?
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Do you hypo pigment (lack of pigment on the skin)?
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Are you allergic to hair dyes?
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Do you have glaucoma or any other eye disease?
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Do you have arthritis?
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Do you have high or low blood pressure?
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Do you have sinus problems?
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Do you have any type of hepatitis or HIV?
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Are you allergic to topical anaesthetics? We use anaesthetics containg lidocaine, tetracaine, benzocaine and epinephrine.
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Do you exercise? Excessive sweating will push out the pigment due to the saline produced by your body.

You will need to refrain from heavy exercise for at least one week. Failure to do so may result in pigment being forced out of the tattooed area.

Saline (sweat produces saline) is used to remove tattoos.
 
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What skin type are you? For example: fair, olive, freckled, translucent, dark
And are you: Oily, combination or dry?
 

The above information is valuable to me as your technician as each person’s body is unique, or it may indicate that based on any health conditions that affect healing, it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please email browsauckland@gmail.com to give further information or call Jeni on 021 300065
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Personal Info
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Address:*
Date of birth:*
You must be 18 or older to have this procedure done.
Gender: *
Nationality: *
Phone #:*
Email:*
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Signature:*

Photo ID(s)*
Please take a picture of your government issued photo ID