Are you under the influence of drugs or alcohol?
yesno

FEMALE ONLY: Pregnant or Nursing?
yesno

Do you have a communicable disease?
yesno

List any skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)

Do you have any of the following? (check all that apply)
DiabetesEpilepsyHigh Blood PressureHeart ProblemsBlood Clotting issuesHepatitisHerpes Simplex (Cold sores)Liver DiseaseRosaceaTrichotillomaniaAnaemiaAlopeciaEczema / DermatitisHyperpigmentationAnxiousnessThyroid DisordersAutoimmue DisordersSunburn (past 2 weeks)Immunodeficiency VirusNONE OF THE ABOVE

Are you allergic to latex?
yesno

In the past 6 months have you used Roaccutane / Isotane or Accutane?
yesno

Do you smoke?
yesno

Skin Color
white or very palepale with beige tintbeige to light brown (olive)light to moderate brownmedium to dark browndark brown to place

Hair Color
blondechestnut or dark blondedark brownblackgrey

Eye Color
blue, grey, greendark brownbrownbrownish / blackblack

How does your skin tan?
always burns, never tansalways burns, sometimes tanssometimes burns, always tansrarely burns, always tansrarely burns, tans more than averagenever burns

Are you taking any of the following? (check all that apply)
opioid medicationchemotherapy / radiation therapyTamoxifenPrednisoneThyroxineHRTRoaccutane/Accutane (past 12 months)antibiotics / Doxycyclineprescription vitamin A / RetinolWarfarin / Heparin / blood thinnersfish oils, herbs or VitaminsNONE OF THE ABOVE

Are you currently taking any hair loss formulas? These will need to be stopped 7 days prior and 7 days post each treatment.
yesno

The studio will take mandatory pre-procedural and post-procedural photographs. Please indicate if you will allow your images to be used to show prospective clients, your identity will always be protected.
yesyes, but I want my face blockedno

I understand that this procedure is a permanent change to my skin and body.
yesno

I acknowledge that the studio does not offer refunds.
yesno

I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my SMP.
yesno

I understand that I need to take care of the SMP by following the instructions given to me.
yesno

I accept responsibility for determining the color and position of my SMP.
yesno

I understand that I might get an infection if I don't follow the instructions given to me in regards of taking proper care of my SMP.
yesno

I acknowledge that the SMP procedure will only be carried out at the request of my own free will. I accept that there is a risk that my face or person may suffer harm during and I understand although every precaution will be taken to prevent complications and that whilst complications from this procedure are rare, they can & sometimes do occur.
yesno

I accept responsibility for any complications or negative results that may occur and absolve the studio of any blame resulting therefrom. I will not discuss, post or comment or release any images of my procedure without written consent of all parties & I am liable for any damages and associated legal costs this confidential disclosure may cause.
yesno

I acknowledge that I have been advised that I am not able to donate blood to a blood bank for a period of six(6) months, following any SMP or permanent makeup procedure.
yesno

I indemnify and hold harmless the studio against any claims, expenses, damages, and liabilities.
yesno

I confirm that the information I provided in this document is accurate and true.
yesno