New Client Info and Health Booking Form

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Contact Details
FULL NAME
PHONE NUMBER
DATE OF BIRTH
EMAIL
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How did you find us or who may we thank for referring you? * This field is required.ex. Friend, Google, Instagram, Facebook.
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How did you find us or who may we thank for referring you?
Google search
Facebook
Instagram
Chat GPT or Ai
Other
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Procedures* This field is required.
POWDER BROWS $900
LIP BLUSH TATTOO $950
EYELASH ENHANCEMENT TATTOO $850
SHADED EYELINER TATTOO $1050
COVER UP TATTOO $1100
AREOLA TATTOO
CLASSIC WING EYELINER FROM $950
Other
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Are you currently pregnant or nursing?
YESNO
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Have you been previously tattooed in the area you want to get your cosmetic tattoo done? Skip if you already had a consultation.
YESNO
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Please Take a Photo of the area you wish to tattoo* This field is required.Please take a picture in a good lighting for a review and we'll get back to you ASAP
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What would you like to improve?* This field is required.Think of shape, colour, density, thickness
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Do you presently have any of the following?* This field is required.
Epilepsy/ Seizures/ Pre-existing nerve damage
Cancer/received chemotherapy or radiation in the past year?
Hepatitis (A, B, C, D)
HIV/AIDS/Compromised immune system
Highly prone to scarring or keloids
Easy bleeding/Hemophilia or clotting disorder
Any surgical operations?
Non of the above
Do you smoke?
Other
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Many women are more sensitive during their menstrual cycles, please consider this when scheduling permanent makeup procedures.

Micropigmentation is a tattoo and therefore a minor injury to the skin which takes time to heal. If you are planning a vacation involving sun, swimming or activities that may exert you to the point of perspiration, you must give your skin a minimum of two weeks to heal post procedure. Perspiration has salt, salt removes pigment, it also puts the client at a higher risk of infection.

If you have ANY special events planned within 1-2 weeks following the procedure, it is the client’s responsibility to disclose this to the technician, preferably at time of scheduling. Everyone heals differently, you do not want to show up for your wedding, class reunion or company party with flaking eyebrows, eyelidsor lips.

If a client arrives for their appointment, and any of the aforementioned contraindications and/or conditions, i.e., sunburn, eczema, psoriasis, chronic acne or rosacea, etc. are visible, the technician reserves the right to refuse service, and the client will be charged the equivalent of a “No Show / No Call” fee.

Should a medical release be required to proceed, and the appointment must be re-scheduled, the client will be charged the fee equivalent to a No Show/No Call situation.
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Emergency Contact * This field is required.
PHONE
NAME
RELATIONSHIP
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Please follow the link to read our terms and conditions * This field is required.All clients are required to read “Our Policies” which are available on our website. By scheduling services, clients acknowledge that they have read these documents in full, understand them, accepts terms and conditions and agree to follow Pre-procedure and After care instructions. Failure to do so, may result in rescheduling and/or cancellation of services, and incur fees.
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Have you ever had allergic reaction to any of the following?* This field is required.Check all apply
Lidocaine
Metals
Vaseline
Medication
Latex
Crayons
Anaesthesia
Alcohol
None of the above
Other
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Please list medications or vitamins you are presently taking or medications you took in the last 6 months that you are not longer taking.* This field is required.
Blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin, etc.
Accutane or acne treatments
Steroids
Insulin
Mood altering drugs (antidepressants)
Vit A, E, Omega 3 oils
Hormonal therapy drugs
None of the above
Other
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Do you presently have or previously had any of the following* This field is required.
YES
NO
IF ''YES'' Please specify when
Botox, Lip fillers/ Restylane/ Juve derm
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Row 0, Column 3
Laser treatments/Chemical Peel
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Blepharoplasty (eyelid surgery)/ Eye surgery/Injury/Corneal abrasion/ Lasik within 3 month
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Contact lenses
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Eczema, Psoriasis, Rosacea, heavy Melasma
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Brow or lash tinting (when?)
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Do you use any products containing Retin-A/ Glycolic Acid/ alpha hydroxyl?
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Keloid scars
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Botox, Lip fillers/ Restylane/ Juve derm
Laser treatments/Chemical Peel
Blepharoplasty (eyelid surgery)/ Eye surgery/Injury/Corneal abrasion/ Lasik within 3 month
Contact lenses
Eczema, Psoriasis, Rosacea, heavy Melasma
Brow or lash tinting (when?)
Do you use any products containing Retin-A/ Glycolic Acid/ alpha hydroxyl?
Keloid scars
YES
Row 0, Column 0
NO
Row 0, Column 1
IF ''YES'' Please specify when
Row 0, Column 2
Row 0, Column 3
YES
Row 1, Column 0
NO
Row 1, Column 1
IF ''YES'' Please specify when
Row 1, Column 2
Row 1, Column 3
YES
Row 2, Column 0
NO
Row 2, Column 1
IF ''YES'' Please specify when
Row 2, Column 2
Row 2, Column 3
YES
Row 3, Column 0
NO
Row 3, Column 1
IF ''YES'' Please specify when
Row 3, Column 2
Row 3, Column 3
YES
Row 4, Column 0
NO
Row 4, Column 1
IF ''YES'' Please specify when
Row 4, Column 2
Row 4, Column 3
YES
Row 5, Column 0
NO
Row 5, Column 1
IF ''YES'' Please specify when
Row 5, Column 2
Row 5, Column 3
YES
Row 6, Column 0
NO
Row 6, Column 1
IF ''YES'' Please specify when
Row 6, Column 2
Row 6, Column 3
YES
Row 7, Column 0
NO
Row 7, Column 1
IF ''YES'' Please specify when
Row 7, Column 2
Row 7, Column 3
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Would you like a pigment scratch test?Although rare, there may be an immediate or delayed allergic reaction to pigment. You may take 5-7 days to determine this. A negative patch test result does not guarantee that you will not develop an allergic reaction after procedure. Seek immediate medical attention in the event of a suspected reaction.
WaiveTake
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Possible risks, hazards or complications* This field is required.Please read the following statements carefully and tick to acknowledge your understanding of each.
Discomfort & Healing: Cosmetic tattooing involves needle penetration and varying levels of pain or discomfort depending on individual tolerance. Topical numbing is applied to help manage discomfort. Temporary redness, swelling, or minor bruising is normal and typically clears within 1–24 hours. Final pigment retention depends on skin type and aftercare; any necessary adjustments to color density or shape are made during your follow-up session.
Safety & Anesthetics: We use standard topical anesthetics (Lidocaine, Tetracaine, Epinephrine). While rare, allergic reactions or infections can occur. If an abnormal reaction occurs, please notify us immediately and seek medical advice if needed.
Fever Blisters (Lip Tattoo Only): If you are prone to cold sores or fever blisters (herpes simplex), tattooing will likely trigger an outbreak. Taking antiviral medication (available at a pharmacy or by prescription) prior to treatment is strongly recommended.
Previous PMU (Tick ONLY if applicable): Cover-ups or work over existing PMU done elsewhere require additional paid sessions and are not covered under standard touch-ups.
Lasers & IPL Notice: Laser and IPL treatments can darken or turn cosmetic pigments black. You must always inform your laser technician that you have permanent makeup.
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ACCEPTANCE & FINAL CONSENT (Please check all boxes below to proceed)
Age & Medical Accuracy:I am over 18, not pregnant/nursing, and not under the influence. I confirm all provided medical info is accurate and truthful, and I accept full responsibility for my decision.
I understand 1 complimentary touch-up is included within 1–2 months (after 2 months, full/extra session fees apply). If applicable, cover-ups or work over previous PMU done elsewhere require additional paid sessions. I agree to follow all Aftercare instructions provided today and avoid non-recommended products (e.g. alcohol sanitizers).
Acknowledgment of Risks & Medical Protocol: I have read and understand all listed risks and complications above. If an infection or unexpected reaction occurs, I agree to seek immediate medical treatment (GP/Emergency) and notify my technician.
Photos & Release of Liability: I consent to before/after photos as a condition of service. I accept the permanence of cosmetic tattooing and release the technician from liability for individual bodily reactions.
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ACCEPTANCE: * This field is required.
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Book Your Appointment
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