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
Advertising
Facebook
Instagram
Other
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Procedures* This field is required.
POWDER BROWS $900
LIP BLUSH TATTOO $900
EYELASH ENHANCEMENT TATTOO $700
SHADED EYELINER TATTOO $1000
SOLUTION TATTOO REMOVAL $200
COVER UP TATTOO $1100
SCAR CAMOUFLAGE
AREOLA TATTOO
Patch test
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
Row 0, Column 0
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Row 0, Column 3
Laser treatments/Chemical Peel
Row 1, Column 0
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Blepharoplasty (eyelid surgery)/ Eye surgery/Injury/Corneal abrasion/ Lasik within 3 month
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Contact lenses
Row 3, Column 0
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Eczema, Psoriasis, Rosacea, heavy Melasma
Row 4, Column 0
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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
Row 7, Column 0
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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.
Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.
Infection: Infection is very unusual, however infections can occur if after care instructions are not followed correctly. The areas treated must be kept clean an only freshly cleaned hands should touch the areas. See “After Care” on on our website for instructions on care.
Allergic reaction: Although rare, there may be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the procedure. Seek immediate medical attention in the event of a suspected reaction.
Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance.
Excessive Swelling or Bruising: There may be swelling, redness or minor discomfort following the procedure. Some people bruise and swell more than others. Swelling typically disappears within 1- 24 hours.
Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.
Fever Blisters: (LIP TATTOO ONLY) If you are prone to cold sores or fever blisters, (herpes simplex), there is a high probability that you will get them. It is advised that you call your doctor for a prescription antiviral to help prevent this form occurring.
Many Lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent makeup dark or even black. You must inform your aesthetician or anyone operating such equipment of any tattoos or micropigmentation.
Previously tattooed areas (by not us) will almost always require additional sessions and will be charged accordingly. Some special cases may be considered. In many cases, we cannot accept the work unless the old tattoo is very light and has faded out. If you were previously microbladed, it is also hard to follow the old work unless it was done correctly.
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ACCEPTANCE: * This field is required.I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. I absolutely understand and accept that such procedure is a process, often requiring multiple applications of colour to achieve desired results. To achieve the best results, you will be required to return for at least one control procedure 4 to 6 weeks after the initial application. Cost of the additional session is $200. Previously tattooed areas (by not us) will almost always require additional sessions and will be charged accordingly. Some special cases may be considered. A minimum healing period of 6-8 weeks is required before a touch-up procedure can be performed. Procedures with the interval more than 2 months are not counted as additional. I understand that the colour selection and results in all procedures are not an exact science and that the actual colour of the pigment may be modified slightly, due to the tone and colour of my skin. Taking before and after photographs of the said procedure(s) are a condition of such procedure(s). Implanted pigment colour can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the colour with future applications. I state that I’ve received written after care instructions and I will strictly adhere to such instructions. understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent makeup dark or even black. I agree to inform my aesthetician or anyone operating such equipment that I have permanent makeup. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics. I acknowledge micro-pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: minor and temporary bleeding, bruising, redness or other discolouration, swelling, poor colour retention or loss of pigment, scarring, inconsistent colour, infections, misplaced pigment, hyperpigmentation fanning or fading of pigments. I am aware that if an infection occurs after I have received micro pigmentation, that I am to seek immediate medical treatment from either my primary physician or hospital Emergency Room, and that I must notify my practitioner. There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. If patch test is waived, I release the technician from liability if I develop an allergic reaction to the pigment. I accept the permanence of the micro pigmentation procedure as well as the possible complications and consequences of the said procedure(s). I fully trust my service provider to perform the procedure of the micro pigmentation and agree that the service provider is not responsible for any individual reactions of my body.I have read and understand the risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and the questions have been answered truthfully to the best of my knowledge. I accept full responsibility for the decision to have this cosmetic tattoo work done.
Clear
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Book Your Appointment
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Booking FeeBOOKING A NEW SERVICE REQUIRES TWO SESSIONS (we will book your second appt in person). A NON REFUNDABLE BOOKING FEE IS REQUIRED TO HOLD ANY APPT AND WILL BE APPLIED TO YOUR TOTAL COST.
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