Consultation Form – Cosmetic Tattoos

Consultation Form – Cosmetic Tattoo

Name*
First Last
Address*
Street Address Address Line 2 City State Post code Country
Phone*
Email*
Date*
DD slash MM slash YYYY
How did you hear about us?*
What service are you having?*
Have you had this service before?*
Have you had any reactions?*
Medical History*
Please check any that apply to you.
- None of those listed
- Sensitive eyes
- Watery eyes
- Oily skin
- Eczema or Dermatitis
- Eye disease
- Epilepsy
- Recent Eye Surgery
- Currently pregnant or lactating
- Alopecia (hair loss)
- Bell’s Palsy (facial Paralysis)
- Inflammation of the skin
- Blepharitis
- Wear contact lens/glasses
- Trichotillomania (Hair Pulling Disorder)
- Conjunctivitis
- High/Low blood pressure
- Haemophilia
- Thrombosis
- Keloid
- Herpes
- Seizures
- Oedema
Allergies*
Please check any that apply to you.
- None known
- Latex/band aids
- Medical tape
- Hay fever
- Glue/bonding agent
- Adhesives
- Sulphonamide
- Nickel
Are you taking HRT?*
- Yes
- No
Have you or are you taking Roaccutane?*
- Yes
- No
Have you had any treatments for cancer?*
- Yes
- No
How long ago?*
Are you currently receiving treatment from a medical Practitioner?*
- Yes
- No
Have you got any other allergies/conditions?
Not sure if you are allergic? Book in for a free consultation and patch test. This will take half an hour and we will be able to go through the process of applying lash extensions with you. The patch test includes using all our products on your skin (glue, tape cleanser etc), to determine if you are a candidate for eyelash extensions. However it does not 100% guarantee that after a fullset of eyelash extensions you will not react, it is just an indicator to whether or not you are allergic to any of our products before committing to any services. This needs to be scheduled at least 48hrs before your first appointment.
Patch Test Waiver*
I hereby waive the 24/48 hour patch test for the agreed service on the suggested area. I choose to have the technician perform the service without the patch test, I am aware that I could have an allergic reaction that may require treatment from a health care professional or hospitalisation.
- I agree to continue without a patch test.
- I would like to have a patch test.
I acknowledge that I have read and understood the terms and conditions set by Minht Artistry. I verify that I am over the age of 18 and confirm that all the information I have provided is true and I have answered all questions to the best of my knowledge. I give Minht Artistry permission to complete the beauty treatment.
Consent*
I understand that:
* that all semi-permanent procedures carry with them the possibility of complications & consequences including but not limited to fading of skin pigments, risk of infection, scarring, swelling, eye damage, inconsistent colour & bruising.
* the actual colour of the pigment may be modified slightly due to the tone of my skin.
* having a lip procedure may inflame cold sores, especially if I suffer from cold sores.
* If I want the best results from the procedure, then I will need to book in for 4-6week follow up appointment (touch up)

I acknowledge that:
* I do not have any skin condition that may affect the area of the tattoo.
* the actual colour of the pigment may be modified slightly due to the tone of my skin.
* by agreeing to this release form I have given the full opportunity to ask any & all questions I might have about obtaining a tattoo from Minht Artistry.
* all my questions have been answered to my full & total satisfaction.
* I am not pregnant or breast feeding.
* I must disclose if I am prone to Keloid Scarring
* I am free of communicable disease.
* I must disclose information about any medication I am currently taking or have been in the last 3 months
* it is not reasonably possible for the associates, agents & representatives of Minht Artistry to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo & I agree to accept that such risks are possible.
* Tattooing is a semi-permanent change to my appearance.
* obtaining of my tattoo is my choice alone & I consent to the application of the tattoo & to any actions or conduct of the associates, agents or representatives of Minht Artistry that are reasonable necessary to perform the tattoo procedure.
* there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the technician in the event I feel lightheaded, dizzy &/or faint before, during or after the procedure.
* that infection is always possible as a result of obtaining a tattoo particularly in that event that I do not take proper care of my tattoo or fading of pigments. I have been advised of the signs & symptoms of infection that indicate a need to seek medical care.

Terms & conditions for all appointments

* I agree to release & forever discharge Minht Artistry & it’s associates, agents,
officers & shareholders from any & all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures & conduct used to apply my tattoo & all tattoos applied by Minht Artistry & it’s associates, agents & representatives in the future.
* I agree to follow all instructions concerning the care of my tattoo. If any touch-ups are needed because of my own negligence it will be done at my own expense.
* The technician will explain each step of the procedure during the service.
* If an allergic reaction does occur I will seek medical attention immediately.
* I must keep my eyes closed during any eye procedure(s).
* Retention of the colour is dependent on each individual, skin type and aftercare.
* If I do not follow the correct aftercare procedure then the service may no longer be available to me.
* A $50 non-refundable booking fee is required for all cosmetic tattoos and will be taken off the total price of the service on the day of the appointment.
* A cleaning fee of $10 will be charged if I arrive to my appointment with mascara, makeup or moisturiser on.
*I understand that if I do not cancel my appointment 48hrs before my appointment and/or I do not attend my appointment. The $50 booking fee is forfeited or I will need to pay the $50 fee before another appointment can be scheduled.
* I agree for Minht Artistry to take photos for marketing, advertising and training purposes.
* If I am more than 15 minutes late to my appointment, the appointment will be cancelled and a cancellation or rescheduling fee will be charged before another appointment is made.

COVID Agreement

* I have not been overseas in the last 4 weeks.
* I am currently not Covid postive.
* I have not been in contact with anyone who has been interstate or overseas in the last 4 weeks
* I do not have any cold or flu symptoms.
I agree to the terms and conditions & understand the above risk associated with this procedure.
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