Patient Intake Form - Booking Confirmation

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Cosmetic Tattoo Intake Form

Please complete this form prior to your first appointment. Your answers will better help us meet your needs and ensure that you have a happy and satisfying experience.

"*" indicates required fields

Procedure Information

Select Your Procedure*

Patient Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Date of Birth*

Email*

Your email address will be used for appointment confirmations.

Subscribe to our Newsletter?*

Select Yes or No to add your email to our newsletter and receive periodic updates and special promotions.

Emergency Contact Phone*

Medical History

Have You Ever Had Any of the Following?

Have you ever had an allergic reaction to any of the following?

Any diseases, disorders or allergies not listed above:

Have you received chemotherapy or radiation in the past year?*

Are you currently pregnant?*

Are you currently taking medication that thins the blood?*

List any medications you have been taking in the past 6 months:

Do you bruise or bleed easily?*

Do you scar easily?*

Chemical or laser peel within 6 weeks*

Do you have healing problems?*

Are you currently under the care of a physician?*

If yes, please explain.

What are the main concerns relating to your requested procedure?

What would you like to improve?

Care, Advice, Risks & Consent

Pre & Post Care Advice Consent*

I have read and fully understand and agree to the Cosmetic Tattoo Pre-Procedure Advice (PDF), Cosmetic Tattoo After-Care Instructions (PDF), Cosmetic Tattoo Procedure Consent (PDF), Cosmetic Tattoo Risks, Hazards & Complications (PDF), and any risks involved with the use of topical anesthetic and I therefore consent to the use of the anesthetic for the cosmetic tattoo procedure. I agree to follow pre- and post-procedure advice closely.

Age & Cognitive Consent*

I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated semi-permanent tattoo procedure. The general nature of cosmetic tattooing, as well as the specific procedure to be performed, has been explained to me.

Additional Risk Consent*

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science but an art. I request the semi-permanent skin pigmentation procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences of the said procedure. I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my procedure. I acknowledge some of these potential adverse changes may not be correctable.

Patch Test Consent*

There is a small possibility of an allergic reaction to numbing agent and/or pigments. A patch test is offered however it does not ensure a client will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to the pigment. You may take a 5-7 day patch test to determine this.

I consent to the patch test.

I waive the patch test.

Disclosure & Releases*

Please read and check each line. Every line must be checked to submit this form.

Photo Release Consent & Social Media

I would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising. We also like to tag our clients in photos used on our Instagram profile! Please indicate if you’d like to allow this or not below.

Yes, feel free to use them

No, please do not use them

Yes please tag me on Instagram

No, please do not tag me

I certify that I have read and understand the above paragraphs, documents, and have had explained to my understanding the consents and procedure risks, expectations and details. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.

I give Louveau Aesthetics permission to perform my microblading procedure.

Client Printed Name*

Client Signature*

Comments

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