Client Intake Form

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CLIENT INTAKE FORM

Confidential Personal and Consultation Record:

To help us with your procedure, please complete this form as best as possible
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Name* This field is required.
First Name
Last Name
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Date of Birth:* This field is required.
Date
Month
Day
Year
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Occupation:
What do you do for work?
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Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Cell Phone Number:* This field is required.
Please enter a valid phone number.
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Home Phone Number:
Please enter a valid phone number.
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Email:* This field is required.
example@example.com
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How did you hear about this procedure?
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How did you hear about us?
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Have you ever had a regular Tattoo?
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What do you hope to achieve from the treatment?
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Media Consent & Release Clause
I understand that photos/videos may be taken before, during or after my treatment for professional and marketing purposes, unless I decline in person before my session.
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Confidential Medical Questionnaire/Personal Record

Please fill out the questions that follow:
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Please indicate if you have/had any of the following:
Abnormal Heart Condition
Rheumatic Fever
Hemophilia
Anemia
High Blood Pressure
Low Blood Pressure
Prolonged Bleeding
Fainting Spells or Dizziness
Palpitations
Healing Problems
Bruise or Bleed Easily
Cerebral Incidents i.e. Stroke
Epilepsy
Diabetes
Kidney Disease
HIV / AIDS
Hepatitis
Herpes
Eczema
Keloid Scars
Scar Easily
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Are you undergoing any treatment for any condition at the present moment?
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List all the medications you have been taking in the last 6 months:
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Do you take aspirin or ibuprofen regularly?
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Name of Your Doctor:
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Address of Doctor
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Do you suffer from any allergies (including latex)? Please list any:
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Have you had any cosmetic procedures in the past? i.e. Hair transplant, botox, dermal tiliers:
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Date of Application:* This field is required.
Date
Month
Day
Year
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Reservation Fee* This field is required.This Fee is a refundable reservation fee. Any cancellations must be made within 7 days of the procedure.
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ORDER SUMMARY
Total costUSD
RESERVATION FEE
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Total cost
Payment Methods
Credit Card
First Name
Last Name
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
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Signature* This field is required.By signing below, I give my consent to proceed with the SMP treatment and confirm that I have read and agreed to the Terms and Conditions & Privacy Policies on our website
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