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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.

Ar you under 18 years of age?
Are you prone to keloids?
Are you pregnant nursing, harvesting eggs, or trying to get pregnant?
Do you have Eczema, Psoriasis, or Dermatitis in or around the tattoo area?
Have you taken Accutane within the last 12 months?
Do you have Hemophilia-Bleeding Disorder?
Do you have any Heart Conditions/Pace Maker/Defibrillator?
Do you have any scars, piercings or have you experienced any trauma in the tattoo area?
Have you EVER had Shingles on your face? Even years ago.
Do you suffer from Trichotillomania (obsessive pulling of body hair)?
Do you have any platelet Disorders?
Do you have any moles/raised areas/pimples in or around the tattoo area?
Do you have any deep wrinkles in the tattoo area?
Do you have any of the Thyroid conditions?
If you selected eyebrows, have you had a hair transplant for your eyebrows in the past?
Do you have an active Cancer of any kind or have you had chemo/radiation in the last six months?
Do you have Rosacea?
Do you have MRSA?
Do you have extremely thin skin (Transparent or Translucent or very vascular)?
Do you exercise more than 5-7 times per week and for more than an hour at a time?
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.
Do you have an Auto-Immune Disorder of any kinds? You MUST have cosent from your dr for the procedure.
Are you a Fitzpatrick type I or II?
Do you smoke daily? Smoking will make the pigment fade faster and change color over time.
Do you take any of these medicatons?
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