Book an Appointment

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

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Tick any boxes that relate to you.

Cold sores

Herpes

Diabetes

Glaucoma

High blood pressure

Blood clotting

Accutane / Roaccutane / Isotretinoin - Or in the last 12 months

Oily skin

HIV / AIDS

Pregnant / Breast feeding

Latex allergy

Surgery in the past 3 months

Allergies - Penicillin

Heart problems

Collagen / Facial filler

Alopecia

Hemophilia

Hepatitis A B C

Epilepsy

Under 18 years of age

I understand that when providing the information in this form I consent to the use of this information for provision of services by the therapist. I consent to the uploading of my personal information to a cloud computer network. The information in this form and associated with the treatment will be held in accordance with the NZ Privacy Principles & the Privacy Statement. *

Yes

*

I understand that all semi-permanent procedures carry with them the possibility of complications and consequences including but not limited to fading of skin pigments, risk of infection, scarring, eye damage, inconsistent color, and bruising. I do not have any skin conditions that may affect the area of the tattoo. If I want the best results from the procedure, then I will need to book in for a 4-8 week touch up. I understand the actual colour of the pigment may be modified slightly due to the tone of my skin. This treatment is my choice. I understand that I cannot donate blood 4 months after the treatment. I understand that the provider of this procedure takes no responsibility for any possible complications and consequences that may result from the procedure.

I understand