CLIENT INFOBefore your scheduled appointment, please read and complete all fields below. Name * First Name Last Name Date Of Birth MM DD YYYY Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact Name First Name Last Name Emergency Contact Phone # (###) ### #### What permanent makeup service are you interested in? * Microblading Combo Powder Brows Are you currently under the care of a physician? * Yes No If you answered yes to the above, please explain why: Do you suffer from any of the following conditions? * Please click all that apply Allergies Moles or freckles at site of tattoo Hepatitis Heart Problems Hemophilia Diabetes Skin Problems Keloids Eye Problems Epilepsy Thyroid Other None Are you taking any medication(s) which thin the blood? * Yes No Are you taking other medications including anti-depression or mood altering drugs? * Yes No Are you on medication for a thyroid issue? * Medications that are used to treat thyroid issues can have an affect on the healed result.* Yes No Please list any other medications you take on a regular basis * I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and I agree as follows: * I understand that two procedures are highly recommended. The follow up procedure is included in my service total and must be performed between 6-8 weeks after my initial procedure. If failed to schedule between this time frame, the follow up will be at the cost of the client. If I have any condition that might affect the healing of this tattoo, I will advice my tattooer. I am not under the influence of alcohol or drugs. I do not have medical or skin conditions such as but not limited to: acne, scarring, keloids, eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. I acknowledge that is not reasonably possible for the representatives or employees of this tattoo shop to determine whether or not I might have an allergic reaction to the pigments or processes used in my tattoo and I agree to accept the risk that such a reaction is possible. I acknowledge that infection is always possible as a result of the obtaining of a tattoo, particularly in the event that I do not take proper care of my tattoo. I have received aftercare instructions and I agree to follow them as my tattoo is healing. I agree that any touch up work needed, due to my own negligence, will be done at my own expense. I realize that variations in design and color may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo. I acknowledge that a tattoo, also known as body art, is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my tattoo. To my knowledge, I do not have a physical, mental or medical impairment which might affect my well being as a direct or indirect result of my decision to have a tattoo. I acknowledge that tattoo inks, dyes, pigments have no been approved by the FDA and the health consequences of these products are unknown. There are no refunds for this procedure as results vary and individual results are not guaranteed. I give permission for pictures of my service to be used as portfolio or marketing on social media platforms, as well as printed. I understand that the procedure and results cannot be guaranteed as there are many variables that contribute to the final result. I release Natalie Sullivan and Darling Artistry of all claims and injury, seen or unseen, that occur as a result of this procedure. I acknowledge I am over the age of 18 and that I have truthfully represented to my tattooer that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure. * By typing my full name below, it serves as my signature for all intents and purposes. * Today's Date * MM DD YYYY Thank you!
