Client Intake Form

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This form is designed to give the information needed to make an informed choice of whether or not to undergo a Permanent Cosmetic Tattoo, Paramedical Tattoo or Artistic Tattoo Procedure. If you have any questions, please do not hesitate to ask.


Topical Anesthetic Advice

For any Permanent Cosmetic/Tattoo procedure, a numbing cream and/or gel may be used. The products are formulated to be safe and can be purchased over the counter. The anesthetic is placed over the treatment area for 5-20 minutes and then carefully removed prior to the treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness or swelling that may last anywhere from one to four days after your procedure.

Some people experience severe reactions to anesthetics, such as difficulty breathing, seizures, drop in blood pressure, and in extreme cases, death. Swelling, rashes, blistering, dryness, or any other symptoms are associated with an allergic reaction. Your technician cannot accept responsibility if the treated area does not respond to the numbing cream. Each individual is different according to skin type. Some clients may experience complete numbness, while others may experience some discomfort. Sensitive clients may experience light sensitivity or discomfort.

I have read and fully understand the information above regarding any risks involved with the use of topical anesthetics (numbing cream), and I, therefore, consent to the use of the anesthetic(s) for the Permanent Cosmetic/Tattoo procedure.
By signing you acknowledge, understand, and agree to the following terms:

  • You are 18 years of age or older (for permanent cosmetics) and 16 years or older with parental consent (for artistic tattoos) and you have truthfully represented to your technician that undergoing this procedure is by your choice alone.
  • You are NOT pregnant nor nursing.
  • You are NOT under the influence of alcohol or recreational drugs.
  • You are NOT using blood thinners or medications that may increase bleeding during the procedure.
  • You do NOT have skin conditions such as severe acne, keloid scarring, eczema, facial psoriasis, keratosis, or moles in the procedure area.
  • You do NOT have uncontrolled diabetes, a history of hemophilia/abnormal bleeding, or any medical condition that may cause difficulties during the healing process.
  • You do NOT have any type of rash or infection anywhere on your body.
  • You do NOT have freckles, moles or sunburn in the procedure area.
  • You do NOT have any sensitivity to dyes or local anesthetics.
  • You acknowledge that you may have an allergic reaction to the pigments or anesthetic cream used and you accept the risk that such a reaction is possible. If you are taking medication and/or have a medical condition that may interact with the pigments or anesthetic cream, it is your responsibility to consult with your doctor prior to booking an appointment.
  • Infection is very unusual but always possible as a result of the procedure, particularly in the event that you do not follow the proper care following the procedure.
  • Skin treatments such as laser hair removal, botox, plastic surgery or other skin altering procedures may result in adverse changes to the procedure area. These changes may not be correctable. You acknowledge that you have not had a chemical peel, laser peel or applied Retin-A within the last 6 weeks.
  • For eyebrow procedures, you acknowledge that no waxing, threading, tweezing or other brow shaping has not been performed within the last 48 hours.
  • You acknowledge that if you have any medical condition(s) you will need a medical note from your doctor.
  • For eyebrow procedures, effort will be made to avoid asymmetry, but our faces are not symmetrical so adjustments may be needed during the follow-up session to correct any unevenness.
  • You will receive aftercare instructions and you agree to follow them. You also agree that if you do not follow the instructions that any touch-ups for correction will be at an additional expense.
  • You acknowledge that the procedure does not start until you are 100% satisfied with the mapping or predraw of your eyebrows, lips, other procedure area, or tattoo design.

Permanent cosmetics is the process of inserting pigment into the upper layer of the dermis (just below the basal layer of the epidermis). It is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are disposable and are disposed of after use. Cross contamination guidelines are strictly adhered to.

Although permanent cosmetic tattoos are effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

Generally, the initial results are excellent; however, a touch-up is required after healing is completed. The final result will often not be obtained without returning for a touch up visit to possibly reshape or augment areas. This is usually done within 6-8 weeks after the initial appointment.

Initially, the color will appear more vibrant or darker compared to the end result. Usually, within 5-7 days, the color will fade 30-40%, soften and look more natural. The pigment will fade over time. Additional touch-ups performed annually are often recommended to boost color.

Paramedical tattooing is used specifically to address medical conditions and concerns, such as scar camouflage, areola restoration after breast surgery, or to conceal vitiligo, among other conditions. The purpose is to improve the appearance of scars and stretch marks but the procedure is not intended to make them totally disappear.

It is important to note that paramedical tattoos are often performed on skin that has already received some type of trauma, and there is a risk that the paramedical tattoo procedure could cause additional trauma to the skin area, including but not limited to hyperpigmentation, although care is taken to prevent further trauma.

Although paramedical tattoos are effective in most cases, no guarantee can be made that a specific client will benefit from the procedure. A minimum of 2 sessions are required and additional sessions may be required for ideal results.

Please note that certain body parts are more difficult to tattoo, including hands/fingers, stomach, ribs, throat, and face. This factor is taken into consideration when quoting tattoo pricing.

Additionally, tattoos on certain body parts are prone to rapid fading due to constant exposure to the sun and other elements and/or friction. Tattoos in these areas may require more frequent touch ups. These areas include - hands/fingers, face, feet, armpits, and areas with creases. Friction from clothing may also cause your new tattoo to fade faster.
Do you have any of the following conditions? Check all that apply.(Required)
Which Of These Apply(Required)
Emergency Contact(Required)

Consents and Acknowledgements

I understand that photographs and videos will be taken before, during and after each procedure for insurance purposes and will be kept as a part of my client file. I understand that these photographs and videos may also be used for advertising purposes (digital and/or print). By booking and proceeding with my appointment, I agree to have photographs and/or videos with my likeness used for advertising purposes.
I understand that a skin patch test may determine whether or not I will experience a reaction to the products used within 48 hours prior to the treatment; however, I accept this will be inconclusive as to whether I have an allergic reaction at any time in the future. A patch test may also help to determine the risk of hyperpigmentation associated with scar and stretch mark revision procedures, but again may be inconclusivve.
The Food and Drug Administration (FDA) warns that tattoos (including Permanent Cosmetics) may possibly cause irritation and burning during an MRI; however, these issues happen infrequently and are temporary. You are advised to inform all skin care professionals or medical personnel about your permanent cosmetic/tattoo procedure if you are having medical procedures done to the skin or undergoing an MRI.

General Medical Aesthetics Release Form / Hold Harmless

I hereby consent to and authorize Vallen J. Cordon to perform the above selected treatment.

Although it is impossible to list every potential risk and complication, I have been informed of the possible benefits, risks, and complications of this treatment. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the practitioner immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history as needed. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential.

I have read and fully understand this agreement and all information detailed in my client consent and waiver forms and information presented at the time of booking. I understand the treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment) responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. I also release Vallen J. Cordon (the practitioner) and Solace Ink by Dr. Val (the company) of any liability that may arise from this procedure.
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