Get ready for your tattoo

appointment with Kayla Struyck!

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Date of birth *

Must be in MM-DD-YYYY format to avoid error

Drivers License #: *

+ Let me know who, so I can send them some love! 🤍 *

+ Please elaborate, so we can track our marketing efforts! *

+ What are your social handles? *

Emergency Contact Name: *

Emergency Contact Phone Number: *

PRE-EXISING CONDITIONS WHICH MAY AFFECT YOUR SUITABILITY FOR THE DESIRED PROCEDURES

To help minimize any risks, which might be a part of the procedure(s), the Client should answer the following questions truthfully and to the best of their ability, in order to assist the Specialist in ensuring that the Client is a suitable candidate for the procedure(s) requested. The Client acknowledges that any incomplete or inaccurate answers given to these questions may increase the possibility of complications and unwanted results from the procedure(s), and, as such, confirms that the answers given are true and accurate.

If your answer is Yes on any item, please provide explanation, including dates, durations, frequencies and circumstances as required below.

Are you pregnant or nursing? *

Yes

Are you allergic to any medications? *

Yes

Are you allergic to Latex, Glycerin, Rubber or PABA_? *

Yes

* Are you currently using any topical creams or medications that might affect your skin's sensitivity? *

Yes

Are you allergic to topical anesthetics (lidocain, novocain, epinephrine, etc.)? *

Yes

Are you allergic to topical salves (bacitracin, neomyacin, Neosporin, etc.)? *

Yes

Are you diabetic? *

Yes

Do you have any type of heart condition? *

Yes

Do you have a mitral or prolapsed heart valve? *

Yes

Do you have any joint replacements? *

Yes

Are you required to take an antibiotic before seeing a dentist? *

Yes

Do you have any type of blood disease? *

Yes

Are you hemophiliac? *

Yes

Do you have / have you had any form of hepatitis? *

Yes

Are you on blood thinners (including aspirin, ibuprofen, coumadin, etc.)? *

Yes

Do you have an auto immune disorder? *

Yes

Do you suffer from alcoholism? *

Yes

Are you epileptic or subject to seizures? *

Yes

Do you have glaucoma? *

Yes

Do you have any dermatological disorders (eczema, rosacea, psoriasis, dermatitis, shingles, etc.)? *

Yes

Do you have herpes? *

Yes

Do you have (or are you prone to) cold sores? *

Yes

Do you have (or are you prone to) keloid formation? *

Yes

Do you have trichotillomania? *

Yes

Do you have alopecia? *

Yes

Do you use cortisone? *

Yes

Do you use glycolic acid? *

Yes

Do you use acutane? *

Yes

Do you use Retin-A? *

Yes

Have you used chemical peels? *

Yes

Do you use steroids? *

Yes

Do you have/ have you had any form of cancer? *

Yes

Are you undergoing chemotherapy? *

Yes

Are you currently taking any medications? *

Yes

Have you had any surgeries in the past 12 months? *

Yes

Are you currently under a doctor's care for any particular condition? *

Yes

Do you have Tourette's syndrome or are you prone to nervous tics? *

Yes

Do you have any other disease not already mentioned? *

Yes

Are you planning to have any cosmetic surgery? *

Yes

Do you have other tattoos? *

Yes

Do you tan (tanning beds, lamp, or natural light)? *

Yes

Within the past year have you had any infectious or communicable diseases such as, but not necessarily or limited to, jaundice or hepatitis as well as any condition that might affect the procedure or healing process such as lupus, diabetes or hemophilia? *

Yes

Additional notes or info on any of the above

Are you under the age of 18? *

Yes

Today's Date *

Must be in MM-DD-YYYY format to avoid error

Please sign: *

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AFTERCARE

Leave Tagiderm on area 2-3 days.

After removal of tagiderm, cleanse treated area with antibacterial soap.

Let area air dry, apply a light layer of after care balm or aquaphor.

Keep area moistened for 14 days with aftercare.

Do not pick at the treated area. Light flaking and scabbing will appear.

Avoid swimming pools, sun, and tanning beds the first 2-3 weeks of healing.

IF YOU THINK YOU ARE EXPERIENCING A INFECTION, GREEN PUSS, OR DISCHARGE, EXTREME PAIN CONTACT A PHYSICIAN IMMEDIATELY

Location of tattoo *

Please describe location

Terms & Conditions

I acknowledge thy signing this agreement that I have been 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 I have been advised of the facts and matters set forth below and I agree as follows.

If I have any condition that might affect the healing of this tattoo. I will advise my tattoer. I am not pregnant or nursing. 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 (keloid) eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo.

If I have any type of infection or rash ANYWHERE on my body, I will advise my tattoer.

I acknowledge it is not reasonably possible to the representatives and employees of Garnet Lash to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk that such reaction is possible.

I acknowledge that infection is possible as a result of obtaining 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 while my tattoo is healing. I agree that any touchup work needed, due to my own negligence, will be done at my own expense.

I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin

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 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 or disability which might affect my well being as a direct or indirect result of my decision to have a tattoo.

I acknowledge I am over the age of 18 and that I have truthfully represented to my tattoer 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.

Signature *

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