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Cosmetic Tattoo Client History Form

Let us do this part
Today's Date:
Tue Jun 3 2025 10:27
Cosmetic Tattoo Client History Form
Please read and answer
 
Procedures Desired*
Please list all that apply: Upper eyeliner, partial eyebrows, lip liner, beauty mark, lower eyeliner, full eyebrows, full lip color, scar camouflage, other (please explain).
 
 
Allergies*
Please list any food allergies or allergies such as but not limited to latex/rubber, tattoo ink/pigment, novocaine, lidocaine, benzocaine, tetracaine, lanolin, bacitracin ointment, neomycin or polymyxin B ointment, PABA, or any metals and describe your reaction to them.

If no known allergies put N/A.
 
 
Eyes/Eyebrows
Please list any of the following that apply: Contact lenses, dry eyes, eye makeup sensitivities, blurred vision, glaucoma, lasik/eye surgery, thyroid abnormalities, alopecia areata (local), alopecia universalis (total), pull out lashes/eyebrows compulsively (trichotillomania), other hair loss (please explain), other eye disorders (please explain), eyebrow/lash tinting and last date of service, botox and last date of service.
 
 
Lips
Please list any of the following that apply: Cold sores/fever blisters (herpes, if yes, an antiviral prescription is required before any lip procedure), lip injections and type and last date of service, any lip augmentation and type and last date, teeth bleaching and date.
 
 
Skin
Please list any of the following that apply: Any other tattoos with location, age, and complications, use of sunlamp/tanning bed, suntanning outdoors, if you are currently being tanned in the area being treated, currently using Retin A and location, if you are currently using glycolic acid, AHA, or Retinol, if you have had injectables such as Restylane, Juviderm, or other fillers, have you ever had a chemical peel, when, and what type of peel, if you have a scar you want to camouflage and the age or scar, any keloids or hypertrophic scars and locations of scars, if you bleed easily, if you have healing problems, if you have other active skin disorders (please explain).
 
 
General Medical*
Please list any of the following that apply: Diabetes, heart palpitations, high blood pressure, mitral valve prolapse or valve implants, pregnant or nursing, hemophilia or other clotting disorders, taken accutane within the last 6 months, currently on any blood thinners or anticoagulants such as Coumadin, aspirin, ibuprofen, or alcohol, autoimmune disorders (please explain), if you have a condition such as hepatitis, HIV, or undergo treatment such as chemotherapy that could affect healing, seizures (please explain), any surgery (please explain), if you are considering and cosmetic or surgical procedures in the near future (please explain), any medications, prescription or non-prescription, that you have taken in the last two weeks, if you are currently under a physician's care for any condition (please explain and include physician's name, city, and phone number.)

If no known medical conditions put N/A.
 
*
By submitting this form I affirm that I will ensure any and all of my questions will be answered by my technician to my full satisfaction. I will also ensure I receive and review a copy of the pre-procedure information sheet and the aftercare sheet. I will ensure I understand and agree to follow them.
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.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Name:*
Address:
Postcode:
Date of birth:*
Phone #:*
Email:*
Signature:*