Cosmetic Tattoo History Form

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. Medication, including some supplements, can affect the healing and color outcome of your procedure. It is important to be completely honest and detailed if you are taking any medication, or if any of the following applies to you.

Full Name *

First Name Middle Name Last Name

Date *

Month Day Year Date Picker Icon

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date

Month Day Year

Phone Number *

This is my: *

E-mail *

Emergency Contact *

Phone Number *

Occupation

Medications

Allergies

ABOUT YOUR HEALTH & SKINCARE

Do you have any current skin concerns?

Do you have any existing cosmetic tattoo? Where and when was it last treated?

Do you have any of the following?

Do you have any allergies including Latex Any adverse reactions to anaesthetic include Dental? In the past 6mths have you used Roaccutane/Isotane or Accutane Are you pregnant or breastfeeding Are you currently planning to conceive Do you smoke Have you consumed alcohol in the past 24 hours Have you EVER (even once) had a Cold sore?

IN THE LAST 6 MONTHS

Facial laser or IPL Facial Fillers Muscle relaxants (botox/Dysport) Chemical Peels Skin Needling

Does your current skin care contain any of the following cosmeceutical ingredients. Many of these will prematurely fade your new tattoo *

AHA's (Alpha Hydroxy Acids) Inc Glycolic and Lactic acids BHA's (Beta hydroxy Acids) inc Salicylic acids Vitamin A (Tretinoin, Retinoic Acid, Retinol) Vitamin C (Ascorbic Acid) Benzoyl Peroxide Hydroquinone / Kojic Acid None of the above

EYELINER TATTOOING ONLY

Please answer:

Are you wearing contacts? Please remove before treatment Have you had any eye surgery Are you using ANY lash enhancing serum Do you/have you ever had conjunctivitis Do you have cataracts any recent/current eye infection

I consent for my Therapist to help me apply topical anaesthetic to my eyes at my appointment as I am unable to do this myself as I must have my eyes closed throughout its application.

I give my consent

Yes No

Eyeliner Design

Lash enhancement - literally thru the lash line to create a soft look with more definition . Smokey Liner - a tailored thicker, edge smudgey/smokey edge to the lines Thick Wedged Liner (Upper only) - a much thicker wedged liner - the angle of the outer liner will point up so as not to draw the eye down. This can be solid or smokey Winged Liner (upper Only) - a "designer liner" more time is needed and incurs a higher fee. This is a speciality liner. The length of the wing is determined by your eyelid fold. Not everyone is a candidate. Shaded winged liner (upper only) - a "designer liner" more time is needed and incurs a higher fee. This is a speciality liner, hard edged on the lower extremity and ends in a shaded appearance fading to nothing. The length of the wing is determined by your eyelid fold. Not everyone is a candidate.

FITZPATRICK SCALE FOR SKIN-TYPE CLASSIFICATION

Skin Colour *

White or very pale pale with beige tint beige to light brown (olive) Light to moderate brown Medium to dark brown dark brown to place

Hair Color (darkest) *

Blonde Chestnut or dark blonde Dark brown black

Eye Color

Blue, Grey, green blue dark brown brown brownish / black black

How your skin tans

Always burns, never tans Always burns, sometimes tans Sometimes burns, always tans Rarely burns, always tans Rarely burns, tans more than average Never burns

ARE YOU TAKING ANY OF THE FOLLOWING *

Style of Brow required? If you change styles after your first session an additional session (3) will usually be required a Change from one style or another is done at Color Boost rates NOT 2nd or 3rd sessions.

Microblading / Feather / hair stroke - perfect for the those that wear little to no makeup as . This style requires color boost 9-15 monthly. Ombre / Soft Powder - for those that like a more defined look (as in you have applied powder to your brows with conventional makeup) - this style requires color boost 12-36 monthly depending on your skin type, skincare, sun Full Powder - for those that wear a lot of makeup and like a defined look.

I understand that if I change my design technique there are additional charges for this & it is not considered a 2nd or 3rd session, but a color boost session.

Yes I understand if I change my technique it is not considered a 2nd or 3rd session, and incurs a higher fee.

Going over existing work or correction work

I understand that if I go elsewhere for touch ups Julie reserves the right to refuse treatment in the future.

If I have existing tattoing that Julie has not performed, and have not made her aware prior to treatment, that treatment may be refused and the deposit will be forfeited. All existing work must have photos sent and in some cases a consultation is required before treatment.

If you have had laser or non-laser removal of brows you must be completely healed prior to treatment - this means NO redness in the area.

INFORMED CONSENT

The nature and method of the proposed Permanent Makeup(PMU) (tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Fading or loss of pigment can may occur depending on your skin and lifestyle. Secondary infection in the area of the procedure may occur, however, if properly cared for, is rare.

I acknowledge by signing below, that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of any permanent cosmetic procedures from Julie Boddy and/or any associates. I also acknowledge that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the fact and matters set below, and I agree as follows:

• I acknowledge that it is not reasonably possible to determine whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such a reaction is possible. I have informed the practitioner of any existing problems.
• I acknowledge that complications are always possible as a result of the permanent make-up procedure, particularly in the event that post-procedural instructions are not followed
• All subsequent procedures incur additional fees. EVERY appointment is charged for.
• I realize that my body is unique and the practitioner or any of the practitioner’s associates cannot predict how my skin may react as a result of the procedure.
• Red heads, blondes & fair skin (Fitz 1-2 skin types) will be red, swollen and pigment MAY not retain at all. Future appointments may not be performed. This is up to the discretion of the technician.
• Results WILL appear softer as the treated area heals. The area/s treated WILL NOT look as DEFINED or as BOLD as the 1st procedure. The healing process can take 3-30 days. Everyone heals differently.
• Most procedures require 2 appointments & color boosts every 9mths - 2 years yrs to keep the color fresh.

• Frequent tanning and sun exposure WILL heal darker & fade the pigment quicker. It is recommended to NOT have a tan/burn (30 days before/after) on your face at the time of your procedure.
• If you are in Menopause and suffer from hot flashes or your core temp runs hot, your pigment will/may fade, blur or not retain.
• Frequent exercising WILL cause the pigments to fade, blur or not retain at all.
• The younger you start to have PMU done, the younger you will be when it can no longer be performed due to scar tissue.
• I acknowledge & understand that pigment implanted on darker skin types ( i.e. Indian, African American, Filipino etc.) the pigment will appear softer and blend more with your own skins melanin (tones) and will not appear as bold or defined as on lighter skin types and the hair strokes will be less visible.
• Alopecia clients- Due to the change in skin texture, pigments may WILL heal powdered.
• I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as to later change or remove the result.
• I understand that skin altering procedures, such as plastic surgery, implants and/or injections may alter and degrade my permanent make-up. I further understand that such changes are not the fault of the practitioner and/or any of the practitioner’s associates. I further understand that such changes in my appearance may not be correctable through further Permanent Make-up procedures.
• Thyroid Conditions & Medicines, WILL prevent the pigment from retaining, fade quickly, blur or change in color. I accept these potential risks & wish to proceed.

• I ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN MADE TO ME CONCERNING THE RESULTS OF THIS PROCEDURE AND THAT THE PROFESSIONAL RECOMMENDATION IS A NATURAL LOOK.
• I accept full responsibility for determining the color, shape and position of the brows that will be applied. Once the shape is approved and the pigment is implanted in the skin, you will not be able to change it.
• I understand the actual color of the pigment may vary slightly due to the tone and color of my skin.
• How your body heals the treated area is 100% out of the control of the technician. This is 100% your bodies job. Even when following the aftercare fading, blurring or poor retention can still happen depending on your skin type & lifestyle. This is NOT the fault of the technician.
• If you decide and approve a shape at the initial appt. and then later decide to change it at a touch up, it may not be possible. This is up to the discretion of the technician if it can be done.
• If you have had tattoo removal prior to seeing Julie, due to scar tissue the pigment may not retain. Further procedures may not be an option and I understand there are NO REFUNDS and accept full responsibility and wish to proceed.
• If you choose to go with a darker color for your brows at your initial appt. and later decide that you want to go lighter (lighten hair) it will not be possible to lighten the color. Removal may be your only option.
• I understand that if any other technician applies permanent makeup over an area that was originally done by Julie; she will no longer perform future treatments. NO EXCEPTIONS!
• In the event of a CAT or MRI scan, please inform your physician of your Iron Oxide Permanent Cosmetics as some pulling or burning sensation (rare) may occur during the procedure.
• I understand that if I do not abide by the strict after care, I WILL ruin my results. The After Care is crucial for optimum pigment retention and results.
• Permanent Makeup is an ART, NOT a science. Client’s results will vary from person to person and using a pencil or powder may or will still be needed. We have no control over your bodies healing process and each time a procedure is done, the pigment will have less retention due to scar tissue.
• Touch ups will not be done any sooner than the required time recommended by the technician.
• I acknowledge that the obtaining of Permanent Make-up procedure(s) is my choice alone, and I consent to the application of the procedure and accept the risks.
• Absolutely NO Refunds after services have been performed.
• I understand that at a certain point as the skin ages, PMU will no longer be performed.

RISKS ASSOCIATED WITH SEMI-PERMANENT PROCEDURE

• I acknowledge & understand that if I have combination/oily/severely oily skin the pigment WILL heal/appear much softer and can look more solid due the over-production of oil glands. The pigment WILL fade quicker, look blurred or more solid. I accept these risks and would like to proceed.

I understand that the provider of this procedure takes no responsibility for any possible complications and/or consequences that may result from the procedure, particularly if I neglect to answer these questions honestly, if I fail to accurately disclose my medical history or if I fail to take pre or post procedure aftercare treatment. I will not hold the therapist resonisible in the event of any damage and shall not be entitled to take action against him/her at Law or Equity for such treatment. I consent to before and after photographs of this procedure, which is at the therapists discretion. I consent to the therapist applying topical anaesthetic products (which I obtained) containing Lidocaine, Tetrocaine, Benzocaine, Epinephrine to the treatment areas and reapplying where necessary. I am over the age of 18 years old. I am not pregnant or breast feeding. I have answered truthfully to all above questions on this form. If I experience any changes, reactions or concerns after my treatment I will notify my therapist immediately for further consultation.

I will allow cropped photos of the area to be used on social media. Photos are essential for EVERY CLIENT.

These will be cropped to give privacy.

Is there ANYTHING I should be made aware of: Any additional information you may wish to give.

I have had explained to me the reason behind a sensitivity or patch test at a $50 fee. I release the therapist from any liability related to any allergies or other reactions to the aplied pigments. I agree to go ahead at my own risk.

If I choose to have a patch test I must do this 7 days PRIOR to my appointment and I have made this appointment accordingly.

I choose

Signature *

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My Products

Deposit for Treatment $ 100.00 AUD

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Total $ 0.00 AUD