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Welcome to
Tattoo & Permanent Makeup Services
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Intake Form
First name
*
Last name
*
Email
*
Phone
*
Birthday
*
Year
Month
Day
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Emergency Contact
*
Relationship
*
Phone
*
Health Conditions
Please check all that apply:
*
Diabetes
Blood Clotting Disorder
Autoimmune Disorder
Keloid Scarring
Hepatitis B
Hepatitis C
HIV
Metal Allergy
Adhesive Allergy
Heart Condition
Epilepsy/Seizures
Skin Conditions (eczema, psoriasis, dermatitis, etc.)
Fainting Spells
Latex Allergy
Lidocaine Allergy
Pigment/Ink Allergy
None
Other (see field below)
Other Allergies (if applicable)
Medications
List any medications you are currently taking, including blood thinners, antibiotics, steroids, or acne medication (accutane). If not applicable, put 'None'
*
Pregnancy & Nursing
Are you pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Recent Procedures (Last 6 Months)
Check all that apply:
*
Chemical Peels
Laser Treatments
Microneedling
Surgery Near Tattoo Area
Sunburn or Active Irritation
Botox / Fillers
Use of Accutane (min of 12 months)
None
Lifestyle Factors
Do you tan frequently?
*
Yes
No
Do you sweat heavily at work or during workouts?
*
Yes
No
Signature
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