Lust Aesthetics Cosmetic Tattoo Consultation Form

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Please complete this form as soon as practical before your appointment.

Email *

Full Name *

Residential Address *

Phone Number *

Date of Birth *

YYYY

Emergency Contact

Allergies - Please list everything not matter how small

Previous Reactions to Beauty Treatments - Latex,Wax, Tint, Solutions, etc

Medical History - Please tick all that apply

Previous Cosmetic Tattoo in the area to be treated

Acne

Hormonal Imbalances or Thyroid Conditions

High/Low Blood Pressure

Circulatory Disorders

Eczema/Dermatitis/Psoriasis/Rosacea

Skin Cancer

Diabetes

Epilepsy

Pace Maker

Loss of tactile Sensation

Skin Sensitivity

Claustrophobia

Heart Condition

AutoImmune Disease

Keloid Scarring

Hyperpigmentation

Bleeding Disorder

Blood Borne Disease - Hiv, Hepatitis Etc

Bruise Easily

Bleed Easily

Medical Conditions not mentioned above?

Have you had any Surgeries in the past 12 Months in the treatment area? Or any Lust Aesthetics should be aware of to make your experience comfortable?

Please List any Current Medications, Supplements and Vitamins you take.

Do you wear Contact Lenses? - if yes please remove prior to Treatment involving Eyes *

Yes

Have you had Radiation/Chemotherapy/Cancer Treatments or been diagnosed with Cancer in the last 12 months? *

Yes

Do you use any products containing the following Ingredients?

Accutane

Glycolic Acid

Lactic Acid

Salicylic Acid

Vitamin A Derivatives (i.e. Retinol)

Any other Prescription Skin Care Products?

Have you recently had any Chemical Peels, Microdermabrasion or Light Therapy in the last Month? If Yes, Please give details.

Have you had Cosmetic Injectable Treatments in the past 6 months? If so, approx what date & what area?

Have you read and understood all the Terms and Conditions required before your Tattoo Appointment? (Located in Booking Email as well as on Lust Aesthetics website - under Booking Terms and Forms) *

Yes

Have you ensured that you are able to provide your own numbing gel and consent to Lust Aesthetics applying it through out procedure (link to numbing in your booking email and on the website under Cosmetic Tattoo Information) *

Yes

The numbing gel you provide will include Lidocaine, Tetracaine and Epinephrine - Have you had previous reaction to any of these medicines? *

Yes

Do you have any questions or notes you would like to ask/tell Lust Aesthetics prior to your treatment?

How did you hear about Lust Aesthetics? *

Two Step Process - Please acknowledge that you understand that Cosmetic Tattoo is a 2 session process, generally 10-12 weeks apart. A second session will be booked for you after your initial appointment, and this will be at an additional cost. (Sometimes 3 are required as per client contract) *

Yes, I acknowledge this is a two step process

I consent to the use of photos and videos for marketing and educational purposes. (You can remain anonymous through cropping and no use of your name - just let us know) *

Yes

Points of Acknowledgement

BLEEDING - This is a small side effect, some people may bleed slightly during the procedure, some may bleed a little more. This is due to the clients own body conditions. The more excessive the bleeding the harder the ink is to implant in the skin. Therefore a third session may be required. Lust Aesthetics isn't to know if this extra session is required until the skin has healed. Therefore any extra touch up sessions will be at the clients cost.

ALLERGIC REACTIONS - These are very rare, but you could be in the small percentage that this happens to. There is no way that Lust Aesthetics could know if you will have an allergic reaction to the products used. If you are in any doubt PRIOR to your appointment, go and discuss your personal situation with a health care professional. Anyone that does get a reaction must contact their Health Professional for advise.

TURNING DOWN A CLIENT - This will always be done with your best interests in mind. If you have a health condition that cosmetic tattoo may negatively impact, I will turn you down for treatment or will require WRITTEN APPROVAL from your Doctor.

Another reason someone may be turned down is if they have existing tattoo in the area, that cannot be touched up, they may require removal first.

VARIATIONS - Due to everyone different skin colouring, healing, medications, lifestyle etc, it is normal to have some slight variances in the pigment colour and how the pigment holds. The colour we choose on the day will be similar to what it heals to, but there are no guarantees it will stay exactly that colour, it may vary by a few shades.

Have you read and understood the information in the statement above? *

Yes

Signature - Please Type Full Name *

Today's Date *

YYYY

Thank you for completing this Consultation Form.

Lust Aesthetics will be in contact with you to discuss your answers if required.

A copy of your responses will be emailed to the address you provided.

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