PERSONAL HISTORY FOR COSMETIC TATTOO TREATMENTS "*" indicates required fields Title* Mr. Mrs. Ms. Miss. Date* DD slash MM slash YYYY Name* DOB* DD slash MM slash YYYY Address* Suburb* State* Postcode* Email Address* Contact Number* Emergency Number* Referred by or how did you hear about us? Name Mark cosmetic tattoo procedure desired* Eyebrow Eyeliner - top Eyeliner - bottom Lip line Full lip colour Beauty spot Scar Camouflage Scalp Pigmentation Other cosmetic tattoo procedure desired other* Do you have any permanent makeup or tattoo in the area to be treated?* Yes No when / where were they done Mark if you have ever had an allergic reaction to any of the following and describe what happened Lanolin Latex Rubber PABA Metals Lidocaine Foods Novocain Dental injection Other drugs Others allergic reaction other* Describe reaction Mark any of the conditions which apply to you Glaucoma Cataracts Blurred Vision Contact Lenses Describe Have you got any of the following? Cold Sores Fever Blisters Mouth Ulcers Herpes around the mouth If yes, how have you been treating this prior to com/ng for/ay: Do you have any important social commitments in the next few weeks?* Yes No Are you or do you have any of the following? Smoker High blood pressure or low blood pressure Diabetic Seizures Pregnant or nursing a baby Undergoing IVF treatment Autoimmune disorders such as HIV Anemic Any skin disorders such as eczema, psoriasis, skin cancer Blood transfusion Recent injuries and surgeries Planning cosmetic or other surgery near the future Hemophilia or any blood clotting disorders Undergoing depression Taking blood thinners Sensitivity to makeup products Used a solarium or have been over exposed to the sun in the past 2-4 weeks Used or using Retina / Accutane / AHA / Glycolic products Had a chemical skin peel Wear a pacemaker Have keloid or hypertrophic scar Bruised or bleed easily Experienced hair loss Laser or IPL treatments Botox or Collagen or other injection Tinted eyebrows or eyelashes? Pull out lashes and eyebrows compulsively List of medication, prescriptions and non-prescription that you have taken in the last two weeks Laser or IPL treatments Location* Laser or IPL treatments Date* DD slash MM slash YYYY Botox or Collagen or other injection Location* Botox or Collagen or other injection Date* DD slash MM slash YYYY Tinted eyebrows or eyelashes Date* DD slash MM slash YYYY Note To determine your skin type, please tick one of the following:Type 1 Skin colour Reaction to first sun exposure yearly Skin type assessed as: Type 2 Skin colour Reaction to first sun exposure yearly Skin type assessed as: Type 3 Skin colour Reaction to first sun exposure yearly Skin type assessed as: Type 4 Skin colour Reaction to first sun exposure yearly Skin type assessed as: Type 5 Skin colour Reaction to first sun exposure yearly Skin type assessed as: Type 6 Skin colour Reaction to first sun exposure yearly Skin type assessed as: Reaction to first sun exposure yearly Skin type assessed as: I acknowledge the above information to be true and correct. It is the client’s responsibility to keep the therapist informed of any changes in health, lifestyle, medication, etc.. By signing this form the client is agreeing that the information given is true and correct to the best of their knowledge.Written permission required by GP/Specialist Informed Consent Client SignatureDate DD slash MM slash YYYY DateTherapist signatureI acknowledge that I have been advised that I cannot donate blood to the blood bank for the following 12 months from today due to this cosmetic tattooing procedure. I agree that have a duty to disclose to the cosmetic tattooist every matter that I know or could reasonably be expected to know which is relevant to their decision to accept me as a client for a cosmetic tattooing procedure. I have been advised of any matter verbally that is not included in the consent form and its attachments. Do not sign this form until you have read and understood the entire contents of pages 1 to 5 and all your questions have been satisfactorily answered.Acceptance* I confirm that I am over the age of 18 and accept to have a cosmetic tattooing. Client SignatureDate DD slash MM slash YYYY Client Name* Cosmetic Tattooist SignatureDateCosmetic Tattooist NameCOSMETIC TATTOOING HOME CARE INSTRUCTION It is quite normal if you feel slight tenderness, dryness in the area. You will need to purchase a small tube of Bepanthen cream. This is an Antiseptic Cream which contains Almond oil and vitamin B5 which assists in the skins natural healing process. Do not use any other product on the treated area for 5 days or the colour can change. Immediately after the procedure, the area treated will look much darker and much more defined colour than the final results, colour will lighten and soften in 3 to 14 days. No soap or cleansers on the treated area for one day, clean area with warm water and cotton wool cloth, then apply smear of Bepanthen cream or Vaseline with a cotton tip. The area where the Tattoo has been applied MUST BE KEPT MOIST for successful healing to avoid scabbing which causes the loss of too much colour. You will need to use Bepanthen cream to hydrate and soothe the Tattooed area, not apply excessive amount of cream, it prevents infections and scabbing. We recommend make-up not be applied over the healing tattoo. This can lead to infection. However, if you must use it, use brand new make-up to minimize infections, especially important with mascara. PROTECTION IS VITAL If you are going out into the sun apply sunscreen to protect the area. Exposure to the sun over time can cause fading and colour change. Cover the area with Vaseline when swimming, chlorine water to avoid bleaching effect. Also avoid using teeth whitening tooth paste. Chemical of any kind could interfere with the healing and colour. Any Glycolic Acid or peels must keep completely away from the Tattoo as it seems to lighten the colour with constant continuous use. Don’t sit in a Jacuzzi, sauna or swim for at least 2 weeks. Steam will open pores and make the colour bleed out. Don’t scrub the treated area, crusting will fall off naturally please don’t force it. If you are having Laser hair removal or resurfacing, please inform the operator of your cosmetic tattoo procedure. No make-up is to be applied on the treated area at least 48 hours. Do not wax, pluck or bleach the hair for at least 3 weeks after the treatment. Do not use prescription Retin-A or Accutane for at least 2 weeks prior to treatment and 4 weeks after the treatment. EYELINER Expect the eye to be slightly tender for 1-3 days, swelling is minimal with most clients it will subside within 24 hours, it is not necessary to apply any after care cream. If needed apply a small amount of Vaseline, less is better. Cold pads can be applied to minimize swelling. Do not use mascara, eyelash curler for 3 days. EYEBROWS Brows will be slightly tender for 1-2 days. They will turn dark for 5-6 days. After 5-6 days they will dramatically soften, normally over 5O-6O%. Immediately after and for the next 24 hours continue to wipe the eyebrows. They will weep a clear fluid (this is normal) Wipe them gently to remove the fluid otherwise a crusting or scab will build up which is not what we want. As the eyebrow skin heals, the area can often form a slight crushing which will be flaking off naturally. Apply the cream minimum of three times a day for the first week. Then twice a day for the following two weeks until the skin healed and smooth. For maximum results cream must be applied every 2-3 hours for the first day and about every 4 hours for the next 5 days. LIPS This area will take the longest to heal. The colour will be extremely bright for 7-8 days. It will then fade to no colour and re-appears after 3-6 weeks. The cream must be applied constantly as your lips will be very dry. Keep moist with Bepanthen cream, if you suffer cold sore use cold sore cream (Zovirax cream) with Bepanthen Cream.