Cosmetic Tattoo Consultation Form Name * First Name Last Name Date of Birth * *it will need you to put month before day, as it’s a different format* MM DD YYYY Area of Tattoo * Eyebrows Lips Medical History * Please tick all that apply I am a diabetic I am currently taking asprin, blood thinning medication or antibiotics I am prone to keloid scarring I am prone to cold sores I have eczema/psoriasis (on the face) I have had HIV/AIDS I have a clotting or bleeding disorder I have active acne in the area I have taken Accutane or similar anti-acne medcation within the last 3 months I use Retionoid/Vitamin A skin cream I have an auto immune disorder None of the above Are you pregnant or breast feeding? * Yes No Do you have any allergies? * Yes No Have you had any of the following treatments in the last 30 days? * Dermal filler Anti-wrinkle injections Light, chemical or laser based facials Major facial surgery Chemotherapy or Radiotherapy None of the above I confirm that I haven’t consumed any of the following within 24hours of my appointment: Caffiene (one small coffee is ok), Alcohol, Energy drinks, Pre work out. * Excessive consumption of the following drinks will encourage bleeding and may impact tattoo pigment retention. Yes No Do you have an allergy to lidocaine, tetracaine or epinephrine numbing agents? * Yes No I confirm the above information I have entered is true and correct to the best of my knowledge * I confirm Name How did you hear about us? Internet search Friend/Family Social Media Thank you!
