Please submit online forms prior to your appointment to go paperless today!

Intake Form

First name*

Last name*

Phone*

Email*

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Position

How did you select us for your services?*

Are you pregnant or nursing?*

Yes

*Cannot legally receive these services if nursing or pregnant in the State of Alaska

Have you had any blood thinners in the last 24 hours?*

Yes

Blood thinners (including alcohol, supplements or medication such as Fish Oil or Aspirin) increase chances of bleeding during service, recomend abstain 48 hours ideally prior to service

Have you had any stimulants within the last 24 hours?*

Yes

Stimulants (including caffeinated beverages or medications) increase chances of bleeding during service, recommend abstain 48 hours ideally prior to service

Do you use tobacco?*

Yes

Tobacco use is stimulating and may slow healing

Are you sensitive or allergic to topical products such as hand cremes, body lotions or makeup?

Yes

Are you sensitive to metals, such as metals used in jewelry?*

Yes

Do you have any allergies or sensitivities we should be aware of?*

Yes

Allergies and sensitivities

Please list allergies.

We have a no latex policy.

Are you allergic or resistant to over the counter level numbing products?*

Yes

Have you ever had cold sores, fever blisters, or any type of herpes?*

Yes

If concerned for breakouts, recommend taking Valtrex the same day as service

Have you experienced Hepatitis or Jaundice during the past 12 months?*

Yes

Do you have a history of stroke or heart attack?*

Yes

Do you have any seizure related conditions?*

Yes

Do you have any heart conditions?*

Yes

Do you have high or low blood pressure?*

Yes

If you answered yes to the last question, which type?

High

Low

Are you wearing a pacemaker?*

Yes

Do you have a history of skin sensitivities? *

Yes

Do you bruise for no obvious reason?*

Yes

Do you have any problems healing?*

Yes

Are you Diabetic?*

Yes

If you answered yes to the last question, which type?

Type 1

Type 2

Do you have any autoimmune disorders?*

Yes

Do you have Arthritis*

Yes

Do you faint or become dizzy?*

Yes

Are you Anemic?*

Yes

Are you under treatment for depression or other mood disorders?*

Yes

Do you take prescription drugs?*

Yes

If you answered yes to the last question, please list prescriptions here

Do you have sinus problems?*

Yes

Do you personally have any history of Cancer?*

Yes

Are you undergoing radiation or chemotherapy treatment?

Yes

Do you have glaucoma or any other eye disease?*

Yes

Do you have any medical condition that has resulted in a medical professional requiring you to medicate with an antibiotic prior to a dental or other invasive procedure?*

Yes

Do you have dry-eye?*

Yes

Do you have prosthetic implants?*

Yes

Do you wear contact lenses?*

Yes

Do you menstruate?

Yes

If close to monthly cyclical cellular turnover (whether you menstruate or not) you may be more sensitive during service due to the natural stimulant released during this time.

Have you had Permanent Makeup or Tattoos done before?*

Yes

If you have had Permanent Makeup or Tattoos done before, have you had any issues healing after they were applied?

Yes

Do you have any moles, skin tags or scarring in the area we'll be tattooing?*

Yes

Do you hyper-pigment due to injury or skin damage?*

Yes

Develop dark pigmentation over injured area

Do you hypo-pigment due to injury or skin damage?*

Yes

Loss of pigment over injured area

Do you intentionally tan? *

Yes

Direct sun or tanning bed tanning fades tattoos, especially exposed on the face

Do you scar easily from minor skin injuries?*

Yes

Do you tend to develop keloid or hypertrophy scars?*

Yes

Do you bleed excessively from minor cuts?*

Yes

Do you routinely use chemically exfoliating products such as Accutane, Retin-A, Glycolic, etc...?*

Yes

Use of exfoliating products must stop at least 2 weeks before and after tattooing. Use of Accutane must stop for 1 full year before tattooing, no exception.

Have you had a facial treatment in the last month?*

Yes

Must wait at least 2 weeks before service in treated area, and 2 weeks to treat the tattooed area.

Have you had a laser treatment in the last 6 months? *

Yes

Recommend waiting at least 1 month before service in treated area, and 1 month to treat the tattooed area depending on strength

Have you had a chemical peel within 6 months?*

Yes

Must wait 1 month or longer after treatment before tattoing can be done, depending on strength. Recommend wait 1 month or longer after tattooing to get treatment done depending on strength.

Are your lips injected with any filler material?*

Yes

Must wait 3 months after receiving filler before tattooing, wait 8 weeks to get filler after tattooing. Filler in face will depend on location.

Do you have Botox injections?*

Yes

Must wait at least 2 weeks before any tattooing can be done, wait two weeks after tattooing to get Botox.

Do you have lash extensions?*

Yes

Cannot tattoo any eyeliner with lash extensions, remove two weeks before tattooing, recommend to wait at least three weeks after tattooing to get lash extensions.

Do you use any lash serums?*

Yes

Cannot tattoo over treatment area. Must stop serum application 6 weeks before and after tattooing.

Do you have any ongoing medical conditions treated or untreated that we should be aware of?*

Yes

Is there anything else we should know that we haven't already asked?*

Yes

Any additional notes, diagnosis, prescriptions or supplements we should be aware of?

Signature

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Please Upload a clear photo of your Legal ID in good lighting here.*

Consent Acknowledgment Form

First name

Last name

Please check boxes to acknowledge

The nature and method of the proposed cosmetic tattoo procedure(s) has been explained to my by Miss Shannon and/or my artist working at Miss Shannon's studio including the unusual risks inherent in the procedure process, and the possibility of complications during and following the procedure(s).

I understand there may be a certain amount of discomfort and the possibility of complications during and following the procedure(s) and that other adverse side effects may include minor and temporary bleeding, bruising, swelling, and/or redness or other discolorations. Fading or loss of pigment may occur. Unevenness in design may occur due to swelling. Secondary infection in the area of the procedure may occur, however, if all aftercare instructions are followed, it is rare.

I have informed Miss Shannon and or my artist at Miss Shannon's studio of any and all health problems.

I acknowledge that complications including infection are always possible as a result of a cosmetic tattoo procedure(s) particularly in the event my post-procedural instructions are not followed

I acknowledge that it is not reasonably possible to determine whether I might have an allergic reaction to pigment, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risks taht such a reaction, althrough rare, is possible. I have informed Miss Shannon and/or my artist at Miss Shannon's studio of any existing problems.

It has been explained to me that immediately afer the procedure(s) have been completed, the color will appear dark and the design will appear to be thicker. It has also been explained to me that within a short period of time (usually 5-7 days) during the healing process, the color will lighten/soften, and the design/procedure will heal thinner than it looked the day if was performed.

I acknowledge that hyper-pigmentation (darkening of skin) or hypo-pigmentation (absence of color in the skin), or scarring is a possibility as a result of my body's reaction to the skin being broken during the procedure, I realize that my body is unique and that Miss Shannon and/or my artist at Miss Shannon's Studio cannot predict how my body will react as a result of this procedure.

I acknowledge that the procedure(s) will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. Tattoo removal is a procedure that may cause scarring and/or disfigurement.

I understand that future laser treatments, plastic surgery, implants, injections, and other skin altering procedures may alter and/or degrade my cosmetic tattoo procedure(s). I further understand that such changes are not the responsibility of Miss Shannon and/or my artist at Miss Shannon's studio and such changes in my appearance may not correctable through further cosmetic tattoo procedures.

I understand that tattoos may cause MRI (Magnetic Response Imaging) artifacts and that is a 1-2% chance of reaction. Within that 1-2% for almost all there will be a warming and/or tingling sensation in the tattooed area from the MRI due to the Iron Oxide properties of some pigments. It is understood that I should advise my phusician that I do have permanent cosmetics (a tattoo) in the event an MRI procedure is prescribed.

I authorize Miss Shannon and/or my artist at Miss Shannon's studio to obtain pre-procedural pictures, and give her permission to use such pictures for publication and/or teaching purposes, as she chooses.

I acknowledge the receipt of written instructions advising me of the proper care of my procedure(s), and after-care product by Miss Shannon and/or my artist at Miss Shannon's studio. I understand the absolute necessity for following these instructions.

I understand that cosmetic tattooing is an art form and not an exact science, and I acknowledge that no guarantees have been made to me as to the result of this procedure. Some skin types will not accept or heal pigment in a consistent manner, your skin and how well you take care of your procedure(s) will determine your result.

I realize that my body and my skin is unique and that Miss Shannon and/or my artist at Miss Shannon’s studio cannot in any way predict how my skin may or may not accept color. I also realize that Miss Shannon and/or my artist at Miss Shannon’s studio cannot predict how many visits it will take to complete my procedure.

The fee for my cosmetic tattoo procedure has been explained to me, including the initial procedure fee, touch-up fees, and maintenance fees. These fees are understood and agreed upon. I understand the total fee for services rendered is due upon completion of the initial procedure and that there will be separate fees for any touch-up work.

I understand that Miss Shannon and/or my artist at Miss Shannon’s studio does not include a free touch-up appointment(s) in their initial procedure price. All touch-up appointments are a separate fee. A touch-up appointment is sometimes necessary to complete, adjust, or fine tune the initial procedure or a maintenance procedure. All follow up appointments will be charged for as needed. We do not accept checks.

I accept full responsibility for determining the color, shape and position of the pigments that will be applied. I understand the actual healed color of the pigment applied will be modified slightly due to my own unique skin undertones.

Due to the fact your approval is obtained prior to final selection of color to be implanted and design applications(s), that all the facts about cosmetic tattooing have either been disclosed or discussed with you, and that you have been given full opportunity to have any and all questions answered, Miss Shannon and/or my artist at Miss Shannon’s studio employs a NO REFUND policy.

Miss Shannon and/or any artist at Miss Shannon’s studio, has the right to refuse service to anyone, at any time, for any reason.

This contract is to remain in effect for as long as I remain a client of Miss Shannon and/or my artist at Miss Shannon’s studio and all its components apply whenever work is being performed on myself by Miss Shannon and/or my artist at Miss Shannon’s studio. It is my responsibility to inform Miss Shannon and/or my artist at Miss Shannon’s studio if any changes have occurred in my medical history.

*Applies to Lip Procedures only. I am aware that the Herpes Zoster 1 Virus (fever blisters/cold sores) may manifest with the lip procedure due to trauma to the lip tissue. The anticipation of a Herpes Zoster 1 Virus breakout may be and is advised to be pre-treated with an anti-viral medication, which are available by prescription only from your doctor. This is your responsibility. Although you medicate properly as advised with an anti-viral, this does not guarantee you will not have an outbreak.

I have read and understand the contents of each paragraph above. I have received no unrealistic warranties or guarantees from Miss Shannon and/or my artist at Miss Shannon’s studio with respect to benefits to be realized from, or consequences of the aforementioned procedure(s).

The decision to have cosmetic tattooing procedure(s) performed is my own and I understand and accept all risks involved, therefore releasing Miss Shannon and/or my artist at Miss Shannon’s studio of any and all legal liability.

Miss Shannon and all artists at Miss Shannon’s studio are exactly that, an artist, a highly trained and skilled artist and makes no claim to be anything more. Permanent makeup/cosmetic tattooing is not a medical procedure but an art form, the art of tattooing. No refunds, no exceptions.

Signature

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