AREOLA COSMETIC TATTOO

INTAKE & CONSENT FORM

Client Name: Date:
Address:
City: State: Zip Code:
Email: Cell #:
Phone Carrier*: N/A Other:
*Required for text message appointment confirmations

How did you hear about us?

Do you presently or have previously had any of the following:
History of MRSA Difficulty Numbing with Dental
BOTOX (Last Treatment: ) Work
Diabetes Blood Thinners (Aspirin,
Hepatitis (A,B,C,D) Ibuprofen, Coumadin etc.)
Forehead/Brow Lift Allergic Reaction to Medications
Easy Bleeding (Lidocaine, Tetracaine,
Face Lift Epinephrine, Dermacaine,
Alcoholism Benzoyl Alcohol, Carbopol,
Abnormal Heart Condition Lecithin, Propylene Glycol,
Take Meds After Dental Work Vitamin E Acetate, etc.)
Chemical Peel List:
(Last Treatment: )
Pregnant/Breast Feeding Now Allergies (Metals, Food, Etc.)
Brow or Lash Tinting List:
Autoimmune Disorder
Oily Skin Diseases or Disorders NOT listed
Cancer (Year(s): ) Skin Products with (Retin A,
Accutane or Acne Treatment Glycolic Acid, Alpha Hydroxyl)
Chemotherapy/Radiation Please list Medications/Vitamins
Tanning (Booth or Sun) you’re taking
Tumors/Growth/Cysts List:
 CLIENT HEALTH HISTORY
Primary Care Practitioner:

Diagnosis/ Reason for Treatment: Previous Treatment:

Breast Cancer Chemotherapy

Breast Reduction Radiation

Cosmetic Lumpectomy

Scars Mature Mastectomy

Current Measurements (if applicable):

TRAM Flap
Right Areola Diameter
Implants
Left Areola Diameter

Notes and plan (for technician only, do not fill out):

TRETINOIN RELEASE
I, , herby certify that to my
knowledge, I have not taken medication Tretinoin or any of the Generic equivalents
to the medication Tretinoin within the last 12 months. I understand that if I have taken
Tretinoin or any of its Generic equivalents within the last 12 months, Cosmetic Tattoo
Center cannot and will not perform any Permanent Cosmetic Procedures and will
reschedule my Permanent Cosmetic Procedure to a date and time after this 12 month
period.

Client Signature:

*Practitioner Signature:

*Required: Can be a photo of their signature inserted into this document or print this page out for them to sign
and scan and send/bring to your appointment. All forms should be emailed to [email protected]
 CLIENT PROCEDURE CONSENT
Please read and initial all lines:
I understand that a certain amount of discomfort is associated with this
procedure and that swelling, redness and bruising may occur.
I understand that Retin, Renova, Alpha Hydroxy and Glycolic Acids must NOT be
used on the treated areas. They will alter the color of the tattooed area.
I understand that sun, tanning beds, pools, some skin care products and
medications can affect my permanent makeup.
I will tell all skin care professionals or medical personnel about my permanent
makeup procedures, especially if I’m scheduled for a MRI.
I accept the responsibility to explain to my technician any desires for specific
color, shape, and/or position for any procedure done today.
I understand that implanted pigment color may slightly change or fade over time
due to circumstances beyond control and that I will need to maintain the color
with future applications and a touch up session within 60 days.
I acknowledge that the proposed procedure(s) involve risks inherent in the
procedure and have the possibilities of complications during and/or following
the procedures such as infection, misplacement, pigmentation, poor color
retention and hyper-pigmentation.
I have been quoted the cost of today’s appointment, which includes one (1) touch
up after 30 days and within 60 days. After the 60 days, a fee will apply and there
will be no refunds for this elective procedure(s).

Consent Release Agreement

This form is designed to give information needed to make an informed choice of whether or
not to undergo a Microblading Semi–Permanent make-up application. If you have questions,
please do not hesitate to ask. Although 3D MIcroblading is affective in most cases, no
guaranteed can be made that a specific client will benefit from the procedure.
This is the process of inserting pigment into the dermal layer of the skin; a form of tattooing.
All instruments that enter the skin or come in contact with body fluids are disposable and
disposed of after use. Cross contamination guidelines are strictly adhered to.
Generally, the results are excellent. However, a perfect result is not a realistic expectation. It
is common to expect touch-ups after healing is completed. Initially, the color will appear much
more vibrant or darker compared to the end result. Usually within 7 days, the color will fade
40%-50% (soften and look more natural). The pigment is semi-permanent and will fade over
time and will likely need to be touched up within 6 months to 2 years.
Possible Risks / Hazards / Complications:
PAIN: There could be pain even after the topical anesthetic has been used. Anesthetics work
better on some people than others.
INFECTIONS: Infection is very unusual. Less than a 0.25% of the population has an allergic
reaction. The areas treated must be kept clean and only touched with freshly cleaned hands.
See “After Care” for instructions.
UNEVEN PIGMENT: This can be a result of poor healing, infection, bleeding, or other causes.
Your follow up appointment will likely correct any uneven appearances.
ASYMMETRY: Every effort will be made to avoid asymmetry but our faces are not symmetrical
so adjustments may be needed during the follow up session to correct any unevenness.
EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs
may help the bruising and swelling. It typically disappears within 1-5 days. Some people do not
bruise or swell at all.
ANESTHESIA: Typical anesthetics are used for numbing the area to be tattooed. Lidocaine,
Prilocaine, Benzonecaine, Tetracaine and Epinephrine in a cream or gel form are typically
used. If you are allergic to any of these please inform your technician immediately.
MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low
level magnet may be required if you need to be scanned by an MRI machine. You must inform
your technician of any tattoos or permanent cosmetics.
ALLERGIC REACTION: There is a small possibility of an allergic reaction. You may take a 5-7
day patch test to determine this. Please choose and initial:

Salon Policies:
I agree to Cosmetic Tattoo Center cancellation and etiquette policies. I understand that
a credit card is required to secure all appointments, 48-hour notice is required for all
cancellations, and cancellations made with less than 48-hour notice my $100 appointment
deposit will not be refunded and will be used as a cancellation/rescheduling fee. Additionally,
children under the age of 12 are not welcome to the salon (they may be a distraction to the
technicians and their clients and could be injured by exposed equipment). I understand that
by violating salon policies, Cosmetic Tattoo Center has the right to refuse service or charge
me, the client, a fee (stated above).
 Image Waiver Consent:
I agree to allow Cosmetic Tattoo Center to use photographs that are taken of me,
the client, during the procedure. These images may be posted online in association
with the procedure, but my name will not be depicted or connected to my image.

Service(s) to be received by client during this session: Left Areola Right Areola

In case of emergency, contact:

Full Name: Phone:

Relationship:

Full Name: Phone:

Relationship:

Special requests, concerns or remarks for technician:

 AFTERCARE INSTRUCTIONS

For the next 6 weeks:

• Apply Protective Balm as needed to keep treatment area moist at all times. Use for
the next 6 weeks. Contains Hydro-cortisone 1% and Vitamins A and D and Aloe Vera.
6 weeks +
• After area is fully healed, keep area protected with an SPF of 15 or greater.
• Expect light to moderate swelling and redness for 2 days following the procedure.
• Sleep with your head elevated the first 2 nights to help reduce swelling.
• Known possible complications are:
• Redness
• Bruising
• Tenderness
• Swelling
• Dry Patches
• Puffiness

DO NOT:
• Use Retin-A or Glycoloc Acids on treated areas.
• Use Peroxide or Neosporin on treated areas.
• Scrub or pick treated areas.
• Expose area to sun or tanning beds.
• Get facials, go swimming, and/ or go in hot tubs for at least 3-6 weeks.
• Dye or tweeze treated areas for a minimum of 3-6 weeks after procedure.
What is normal?
• Mild swelling, itching, light scabbing, light brushing and dry tightness. Ice packs are a
nice relief for swelling and bruising. Aftercare ointments work well for scabbing and
tightness.
• Too dark and slightly uneven appearance. After 2-7 days the darkness will fade,
and once any swelling dissipates, unevenness usually disappears. If it is too dark or
still a bit uneven after 4 weeks, call Cosmetic Tattoo Center (CTC) and we will make
adjustments during the touchup appointment.
• Color change or color loss. As the procedure area heals, the color will lighten and
sometimes seem to disappear in places. This can be addressed during the touch up
appointment, which is why touch up appointments are necessary. The procedure
area has to heal completely before we can address any concerns. Healing takes
about 4 weeks.
• Need a touch up months later. A touch up may be needed 6 months to 1 year after
the first touch up procedure depending on your skin, medications, and sun exposure.
We recommend the first touch up 30 days after the first session, then every 6 months
to 1 year to keep your tattoos looking fresh and beautiful! If most hair strokes have
faded, the entire procedure will need to be repeated. An email photo consultation (or
in person consolation) may be necessary to determine if you need a touch up or a
repeat of the entire procedure.

CAUTION
If the skin around the tattooed area breaks into a heat rash, or small pimples, this is
usually a reaction to the numbing solution and should go away on its own in a couple of
weeks. Please do not pick at it! Call CTC immediately if this occurs so a technician can
make a note of the reaction and follow up to ensure this is not a more serious situation!

(Initial) I have read and understand the above aftercare instructions. If I have
any questions or concerns regarding these instructions I will call Cosmetic Tattoo Center
at 732-758-9800. I acknowledge that how I follow these aftercare instructions and my
own body chemistry has a direct effect on the outcome and results of my treatment.
Mandatory Treatment Service must be scheduled to retouch color or fading. The cost
of this service is free; however, I understand that I am responsible for the cost of the
materials needed for this touch up service (needle, ink, anesthetics etc.)
 REFUSAL OF RECOMMENDED AFTERCARE PRODUCTS
AGAINST PROFESSIONAL ADVICE
This is to certify that at my own insistence, and against the advice of my attending
Therapist/Stylist, I have been informed by them of the possible adverse consequences
of not purchasing and using the recommended Aftercare products as directed.
Product:
Recommended Quantity:
Refused Quantity:
Received Quantity:
Product:
Recommended Quantity:
Refused Quantity:
Received Quantity:

(Initial) I release Cosmetic Tattoo Center and its employees, officers, and my attending
Therapist/Stylist from all liability for any adverse results caused by my refusal to purchase
and use the recommended Aftercare products as directed.

PERMANENT COSMETICS WAIVER AND RELEASE FORM

I authorize my semi-permanent cosmetics professional at Cosmetic Tattoo Center to
perform the permanent cosmetics procedure. The risks of the cosmetic procedure
I have chosen have been disclosed to me. It has been represented to me that no
guarantees, warranties, promises, commitments or other statements as to the results of
this treatment have been made, and I acknowledge that I have received no particular
representations or guarantees, and I am consenting to the procedure at my own risk. I
have revealed or disclosed on the Medical Profile form all conditions and circumstances
regarding my health and health history, medications being taken and any past reactions
to products used or medications taken. Additional conditions could occur or be
discovered during or after the procedure, which could affect my ability to tolerate the
procedure.
I understand the success of my Permanent Cosmetics process requires my careful
maintenance. I understand that I must strictly adhere to all aftercare instructions. I
understand that failure to follow after-care instructions may result in infection, pigment
loss, or discoloration. I agree to and understand all of the above information and
consent that all of the information is correct to the best of my knowledge.
I, as herein signed, release, give up, acquit and discharge my semi-permanent
cosmetics professional and/or anyone affiliated with Cosmetic Tattoo Center from any
claims or damages of any nature. I agree to pay any costs of legal services necessary
to further effect or confirm said release. I further agree that this release shall be in
contemplation of any possible damages, either known or unknown at the signing of
this waiver and release form, and said damages are specifically waived following the
signing of this waiver and release form. I further agree to hold my semi-permanent
cosmetics professional nameless and harmless from any and all damages. I release
my semi-permanent cosmetics professional from any responsibility for pre-existing
conditions I have not revealed, or any consequential change to those conditions that
arises subsequent to the procedure. I understand that I am responsible for any medical
treatment I may need as a result of getting this procedure. I accept full responsibility
for these and any other complications, which may arise or result during or following the
Permanent Cosmetics procedure, which is to be performed at my request.

Please read the following statement and sign and date on the line to indicate that
you have read, understand and accept the following statement:
I, the client herein signed, certify that I have read and had explained to me and fully
understand the above waiver and release form. I certify that I have been consulted
with a semi-permanent cosmetics professional and have read all applicable literature
given to me. I have completed the above forms to the best of my knowledge. I accept
the explanation of potential complications and risks described herein. I certify I am of
sound mind, and I am fully capable of executing this waiver and release form for myself.
I, the undersigned client, acknowledge and fully understand that there might be other
unknown risks not reasonably foreseeable at this time. I, the client herein signed, for the
purposes of documentation, hereby consent to “before and after” photographs, which
may or may not be used for the purposes of advertising.

Client Signature: Date:

I understand and agree to the electronic

signature consent information provided SUBMIT FORMS

Electronic Signature Consent:

By signing this form, I agree that my typed, electronic signature is the legally binding equivalent to my handwritten signature.
Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any
time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.