Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

Are you an existing client? *

Yes

No

Which treatment/s do you wish to have? *

Natural Hair Stroke Brow

Soft Powder Brows

Combination Brows

Corrective Brows

Lip Tattoo

Eyeliner - Lash Enhancement

Eyeliner - Winged

Scalp Micropigmentation (SMP)

Desired Result

Natural

Defined

Bold/ Full Makeup look

Not sure

Do you have any of the following conditions

High Blood Pressure

Diabetes

Antibiotics

Alopecia

Blood Thinning Medication

Hepatitis | Aids

Skin Fitzpatrick *

Never burns, always tans dark

Rarely burns, tans dark easily

Burns minimally, tans easily

Burns easily, tans poorly

Always burns, does not tan

Please indicate your skin condition *

Very dry

Dry

Normal

Combination

Oily

Very Oily

Are you currently taking or have you taken any medication in the last 6 months? *

Yes

No

Please indicate any of the following that apply to your skin

Sun Damage

Acne

Dermatitis | Eczema

Scarring

Rosacea

Moles in tattoo area

Keloid Scarring

Excess Sweating

Cold Sores

Thin Skin

Age Spots

None of the above

Please tick all that apply to your lifestyle

Exercise Regularly

Outdoors Often

Swimming Often

Smoke | Vape

Have you had the Covid 19 vaccination within the last two weeks? *

It is recommended to wait at least two weeks after the vaccine before any cosmetic tattoo procedure.

Yes

No

Preferred contact method

Phone call

Text message

Email

I understand that failing to fill out this form truthfully and correctly may result in my appointment not being able to be completed. *

Yes