Forms | Malissa Inks

CONSULTATION FORM

Please complete the required form to secure your appointment with me.

First name

Last name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Please list any of your allergies here.

Please any medications that you are currently taking here:

I understand that this procedure cannot guarantee 100% results. I allow the center to take photographs for case review which is before and after. I allow the center to use this photograph for a marketing campaign or advertising. I release the center for ay liabilities related to the treatment and result specifially allergic reactions and applied pigmentation. I understad that I need to follow the instructions in terms of pre-procedure and post procedure. I understand that permanent cosmetics are a form of tattooing. I confirm that a healing period is required before the next or before the touch-up treatment. I unerstad that there might be an allergic reaction even though we do skin test 24 hours before. I understand that I might experince infection, minor bleeding, swelling and redness. I confirm that I have read, understand, and answered this consultation form accurately to the bes of my knowledge.

Thanks for submitting!