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Taboo Tushie, Yoni Steam, Ritual Kits, Herbs, Crystals, PMU, Paramedical Tattoo, Scar Camouflage, Permanent Make Up, Reiki, Hair Cut, Hair Color, Mushrooms, Psilocybin, Jewelry, Earrings, Artwork, Nipple Tattoo, Areola RePigmentation, Tarot, Tarot Reading, Ritual, Lip Blushing, Eyebrow Tattoo, Reiki Master, Pranic Healer, Microdosing, Macrodosing

Medical History Questionnaire

I have been fully informed of the risk of tattooing and skin needling. Including but not limited to infection, scarring, difficulties in detecting melanoma, hyper or hypo pigmentation, keloid, and allergic reactions to tattoo pigments, latex gloves, and antibiotics. Having been informed of the potential risk associated with getting a tattoo and skin needling, I still wish to proceed with the tattoo or skin needling application, and I assume any and all risk that may arise as a result of moving forward with the procedure.

Please list an emergency contact with a full name & phone # - you may list 2 if you feel it is necessary, but only 1 is required. Thanks!

Are you now, or have you been under the care of a physician with in the last 2 years?

IF YES, you have seen a physician in the last 2 years, please provide the physicians name, address & phone number:

List all medication you are taking, including Retin A, Glycolic Acid, and Accutane:

List any drug, makeup, skin or food allergies (i.e. soaps or cleansers):

What products do you use for skin care?

Have you recently undergone a skin peel?

Do you presently have or previously had any Botox, Lip fillers, Resatylane/Juvederm?

Do you have, or have you had, any of the following conditions? Please check all that apply

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