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Cosmetic Tattoo
Let us do this part
Today's Date:
Wed Mar 12 2025 05:42
Practitioner:*
Treatment Type:*
Location on body:*
Treatment Price:*
The Cosmetic Ink Clinic
72 High Street
Milton Regis
Sittingbourne
KENT
ME10 2AN
Please read and answer
 
Skin Conditions
Eczema this may make a person more prone to skin infections/ irritation? Psoriasis or other chronic skin conditions, excluding acne and disorders of pigmentation- same complications as eczema? Other Skin Conditions Note: History of keloid scarring- People who have previously had keloid scars, are more likely to develop one at the treated area.
Y
N
Do you have Flu like symptoms?*
IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.
Y
N
Eaten?*
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.
 
Heart/Blood Conditions
Heart disorders some heart defects render individuals more prone to serious heart complications by bacteria entering the blood blood stream. High/low blood pressure can cause light headedness and may be linked to other heart- circulation disorders Haemophilia and other bleeding disorders- may result in excessing bleeding and poor healing Anaemia can slow and prevent the healing process
 
Other Medical Conditions
Epilepsy and persons who have experienced a seizure in last two years. Medication may cause side effects, and poor control of the condition may result in fitting/seizure during treatment. Diabetes long term sufferers may have circulation problems that can prevent sufficient healing. Auto immune disease or other conditions or treatments causing immune-deficiency (e.g. cancer treatments- radio/chemo therapy, HIV) can result in poor healing. Hepatitis C may have circulation problems that can reduce healing properties of the skin; this can result in infection.
 
More Details*
Any other known medical conditions or blood disorders- please state (type N/A if nothing applies).
 
Y
N
Are you Pregnant?*
The immune response may be affected by pregnancy; any infection may affect an unborn child
Y
N
Are you currently Nursing?*
Nursing mothers treatment may interfere with the feeding process; also, any risk of infection is also a potential risk for baby.
Y
N
Medication*
Medications which may cause blood thinning or inflammation of the skin;
• Warfarin
• Apixaban (Eliquis)
• Dabigatran (Pradaxa)
• Edoxaban (Savaysa)
• Rivaroxaban (Xarelto)
• Antbuse
• Roaccutane
• Retin-A
• Alpha Hydroxy Acids
• Hydroquinone
• Photo-Sensitizing Medication
Please give details;

Side affects may affect treatment, healing and recover from treatment
Details:
 
 
Please give details of any other medication and its reason for use


Please list any vitamins and supplements taken.
 
Y
N
Allergic Responses*
Allergies nickel allergy, may result in skin reaction from small amount of metals sometimes present in applied products (inks etc.)
Y
N
*
Are you allergic to local anaesthetic or lidocaine if so please do not use on your own skin prior to treatment
 
Any other allergies? If yes please give details
 
Y
N
Alcohol, Drugs & Smoking*
Alcohol/drugs; Treatment cannot be undertaken if a client is under the influence of drugs or alcohol.
Y
N
*
Smoker?
Y
N
Any other conditions *
Cold sores (Herpes simplex)
Moles within treatment area
Broken capillaries within treatment area
Scars within treatment area
Previous facial surgery

If yes, please give details
Details:
 
Please tick to confirm you understand and agree*
I consent to a patch test. I understand that I may have an allergic reaction to products used within 24 hours and that if I do, I will not be able to proceed with the treatment.
*
I understand that if no allergic reaction is evident within 24 hours that it is not construed that I may not have a reaction at a later date (secondary reaction). I affirm that I will release the technician from any liability for an allergic reaction should I wish to proceed with the treatment.
*
I understand the content of this form and take full responsibility for my actions, thus absolving all other parties their responsibilities if any, associated with the supply of the products and services
*
I confirm I have read the “GDPR- How ‘The Cosmetic Ink Clinic’ collect, use and store data’ statement and give my permission for collection, handling and storage of my personal data for treatment and appointment purposes in accordance with GDPR guidelines.
Images for Marketing
I agree for my pictures to be used for advertising purposes. I understand my name and details will not be published
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Legal Name:*
Pronoun:
Chosen name:
Address:*
Postcode:*
Date of birth:*
You must be 18 or older
Gender:
Phone #:*
Email:
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:
Photo ID
Please take photo(s) of your government issued photo IDs and related paperwork.