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    Cosmetic Tattoo Client History and Consent Form

    Are you currently on any medication? Some medications may affect your healing and colour outcome. These include medications for HRT, depression, diabetes, and immune diseases. Please tick any of the following that may apply to you.
    I am on blood thinnerI am pregnantI am breastfeedingI have heart palpitationsI have hepatitis/HIVI take antibioticsI wear contact lensesI am using lash enhancement serumI have had collagen injections/fillers/BotoxI take Retin A medication and/or topical medicationI am diabeticI take aspirinI have blood clotting problemsI have high blood pressureI have had facial surgery in the last 3 monthsI have allergiesI have eye disordersI have had cold soresI have taken Roaccutane medication in the last 6 months
    Are you prone to any of the following?
    Keloid Scarring (severe elevated scarring)Hyper Pigmentation (darkening skin from injury)
    YesNo
    YesNo
    Description Note:
    Write down details about the service performed (e.g., what colors or products were used, any specific issues the customer had, etc.).

    Consent

    I understand that the description of the procedure is not intended to scare or alarm me. It is simply an effort to fully inform me so I may give or withhold my consent for the procedure(s). I understand that this treatment is for cosmetic purposes only...

    I confirm that all information provided is true and correct.