name
*
First Name
Last Name
date of birth
*
address
*
city
*
state
*
zip code
*
email
*
phone
*
Valid ID Acknowledgement
*
I understand that I am required to present a valid US government issued ID at the time of my procedure
What procedure are you having done today?
*
Stretch Mark Camouflage Tattoo
Lip Blushing
Scalp Micropigmentation
Scar Camouflage Tattoo
Areola Repigmentation
Other (please list below)
If other, please list here:
How did you hear about camoglam beauty inc.?
*
CONFIDENTIAL MEDICAL HISTORY:
Are you currently under medical care?:
*
No
Yes
Have you had any cosmetic injections in the last 3 months?
*
No
Yes
Have you had Botox/Dysport or any other fillers in the last 2 weeks?:
*
No
Yes
Are you pregnant or breastfeeding?
*
No
Yes
Do you have any allergies?
*
No
Yes
If yes, please list allergies here.
Are you prone to cold sores?
*
No
Yes
Are you a hemophiliac?
*
No
Yes
Do you take fish oil supplements or blood thinners?
*
No
Yes
Do you have diabetes?
*
No
Yes
Do you have any heart conditions?
*
No
Yes
Do you have high or low blood pressure?
*
No
Yes
Do you have Hepatitis A, B or C?
*
No
Yes
Are you HIV positive?
*
No
Yes
Do you have any contagious diseases?
*
No
Yes
Do you have any skin conditions?
*
No
Yes
Do you have or have you had cancer?
*
No
Yes
Have you been under the influence of drugs or alcohol in the last 24 hours?
*
No
Yes
Have you had any caffeine in the last 24 hours?
*
No
Yes
Are you currently taking any pain medications, over the counter or prescribed?
*
No
Yes
If yes, please list here:
Are you currently taking any immunosuppresants?
*
No
Yes
If yes, please list here:
Are you taking Acutane?
*
No
Yes
Are you currently using Retin-A or rapid exfoliators?
*
No
Yes
How would you describe your skin?
*
Do you have, or are you prone to...
*
Is there any other information you feel you should provide to your technician; any other issues you wish to discuss or address prior to your procedure?
RISKS AND HAZARDS ACKNOWLEDGEMENT
*
Please check each box to indicate that you have read through it and understand it completely.
COSMETIC TATTOOING CONSENT RELEASE
*
Please check each box to indicate that you have read through it and understand it completely.
AUTHORIZATION/CONSENT
*
Please type your name in full to indicate your agreement to this authorization for treatment.
today's date
*
MM
DD
YYYY
artist
*
Sheena Smith
Donell Swearingin
needle lot #
*
