Intake Form

Please complete this form at least three (3) days before your first appointment. I will review and contact you if I have any questions.

Please be honest with all answers, if details are left out I will be unable to provide you the best possible service.

If you answered yes to any of the questions, please be prepared to discuss your answers/diagnosis.

Answering yes to any of these questions does not always mean that you're not a candidate, but that we may need to discuss further and/or consult your doctor.

First Name

Last Name

Date of Birth

Email Address

Phone

Appointment Date

Ar you under 18 years of age?

Yes

Are you prone to keloids?

Yes

Are you pregnant nursing, harvesting eggs, or trying to get pregnant?

Yes

Do you have Eczema, Psoriasis, or Dermatitis in or around the tattoo area?

Yes

Have you taken Accutane within the last 12 months?

Yes

Do you have Hemophilia-Bleeding Disorder?

Yes

Do you have any Heart Conditions/Pace Maker/Defibrillator?

Yes

Do you have any scars, piercings or have you experienced any trauma in the tattoo area?

Yes

Have you EVER had Shingles on your face? Even years ago.

Yes

Do you suffer from Trichotillomania (obsessive pulling of body hair)?

Yes

Do you have any platelet Disorders?

Yes

Do you have any moles/raised areas/pimples in or around the tattoo area?

Yes

Do you have any deep wrinkles in the tattoo area?

Yes

Do you have any of the Thyroid conditions?

Yes

If you selected eyebrows, have you had a hair transplant for your eyebrows in the past?

Yes

Do you have an active Cancer of any kind or have you had chemo/radiation in the last six months?

Yes

Do you have Rosacea?

Yes

Do you have MRSA?

Yes

Do you have extremely thin skin (Transparent or Translucent or very vascular)?

Yes

Do you exercise more than 5-7 times per week and for more than an hour at a time?

Yes

If you selected a lip service, have you ever had cold sores on your lips before? If yes, you will need an antiviral prescription from your dr.

Yes

Do you have an Auto-Immune Disorder of any kinds? You MUST have cosent from your dr for the procedure.

Yes

Are you a Fitzpatrick type I or II?

Yes

Do you smoke daily? Smoking will make the pigment fade faster and change color over time.

Yes

Please list all medications and supplements you're currently taking.

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Date of Signature

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