Cosmetic Tattoo Intake Form
Please complete this form prior to your cosmetic tattoo appointment. Your responses help us ensure your safety and achieve the best results.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Do you have any allergies? If yes, please list them.
Are you currently taking any medications or have any medical conditions we should be aware of?
Have you had any previous cosmetic tattoo procedures?
*
Yes
No
Which area(s) would you like tattooed?
*
Eyebrows
Eyeliner
Lips
Other
Please briefly describe your desired result or any concerns.
Submit
Should be Empty: