Client Health & Liability Waiver

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Client Health & Liability Waiver - Saline

NOTE: Please be sure to limit/avoid all blood thinners and anticoagulants, such as ASPIRIN, ALCOHOL, FISH OIL/OMEGA-3S, SMOKING, etc., as well as CAFFEINE for 24 hours prior to your appointment.
These things can have a negative effect on sensitivity, healing and retention!

***This is not medical advice, just a warning about potential contraindications. Please consult your doctor before skipping any medications you are prescribed to take to confirm whether it is safe to do so.***

For anyone who menstruates, it is common to experience increased overall sensitivity or reduced pain tolerance during menstruation, so keep this in mind if you wish to plan around that when scheduling services.

Email *

Full Name *

Preferred Name/Nickname

Phone Number *

How did you hear about us? *

Facebook

Instagram

Google Search

Referral

Other:

Mailing Address

Date of Birth *

YYYY

Social Media Name/Handle

Occupation *

Emergency Contact Name and Phone Number
*

Emergency Contact Relationship *

Parent/Child

Partner/Spouse

Sibling/other family

Friend

Other:

Skin Type (Fitzpatrick scale, Reaction to Sun) *

1: Very fair, burns very easily, does not tan

2: Fair, burns easily, can tan with difficulty

3: Fair to medium, sometimes mild burn but gradually tans to olive

4: Olive to light brown, rarely burns, tans to medium brown

5: Medium brown, very rarely burns, tans easily

6: Dark brown, doesn't burn, tans easily

Ethnic Background *

Have you had any vaccines or immunizations within the last two weeks? *

(Vaccinations/Immunizations can cause increased inflammatory responses so it is recommended to wait at least two weeks before or after receiving permanent makeup, tattoos or other such services.)

Yes

Please list all medications you currently take AND what they are prescribed to treat:
(If none, put "none") *

Please list all medications you used to take, but have recently stopped taking (within the last 6 months) and what they were prescribed to treat:
(If none, put "none") *

Do use Accutane? / Did you stop Accutane less than a year ago? *

Yes

Have you been prescribed a steroid within the last 6 months? *

Yes

Do you get chemical or laser peels? *

Yes

Do you use tanning beds or sunbathe? *

Yes

Any surgeries within the last year? If not, put "none"; if so, please describe (procedure & date): *

If under the care of a medical provider, please give doctor's name and contact (phone or location)

Have you received chemotherapy or radiation treatment within the last year? *

Yes

Are you currently pregnant or breastfeeding? *

Yes

Do you have an MRI scheduled in the next 3 months? *

Yes

Please list any allergies (especially to supplements, foods, dyes, medications, metals, skincare ingredients and other materials): *

General Health Screen: Please mark all that apply to you *

Grave's Disease

Heart Disease

Mitral Valve Prolapse

Valve Implants, Pacemaker or Stents

Shingles History/Recent Shingles Shot

Diabetes Requiring Insulin

Prone to Keloids

Seizures

Fainting or Dizzy Spells

Rheumatic Fever

Prosthetic Hip or Joint

Hemophilia

Prolonged Bleeding

Anemia

Circulatory Problems

High Blood Pressure

Low Blood Pressure

Thyroid Disturbances

Kidney Disease

Liver Disease

Hepatitis A B C or D

HIV

Tuberculosis

Trichotillomania

Recent Hair Loss

Vitiligo

Alopecia

Lupus

Other Autoimmune Condition not listed above

Eczema, Psoriasis or other Dermatological Condition

None of the Above

Other:

Required

If you selected Other Autoimmune or any Dermatological Condition, please briefly describe:

Have you ever had Aesthetic/Cosmetic Surgery? If so, please note date(s), procedure(s):
(If not, put "no") *

Have you had Botox or other cosmetic injections (Juvederm, Dysport, etc), or do you plan to in the near future? Please describe:
(Or put "no" if not) *

Do you scar in a raised manner? *

Yes

Unsure/Sometimes

Do scars heal darker than the rest of your skin? *

Yes

Unsure/Sometimes

Any history of sensitivity/reaction to any particular tattoo pigment/ink colors?

Describe Tattoo to be lightened (type, location, size, etc.) *

Saline Lightening can take several sessions to reach desired results, and can be done no less than 8 weeks apart, and no more than 4 sessions per year, without adding undue risk of scarring and damage to the skin. Exact number of sessions required to reach desired results cannot be predicted as everyone and every tattoo is different. *

I understand

Required

I understand that the unwanted pigment may not be successfully lightened to the point that it can no longer be seen. Scarring as hyper-/hypo-pigmentation, discoloration or other damage to the skin may occur during this process and may be permanent. *

I understand

Required

I understand there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration, swelling *

I understand

Required

I agree to partake in this service, and understand the inherent risk of exposure to Covid-19 or other pathogens in public spaces, despite strict sanitation and disinfection protocols in line with CDC and Health Department requirements and guidelines, and agree not to hold Tiger Lily Collective LLC or its representatives responsible should exposure occur. *

I understand and agree

Required

I have truthfully represented that I am at least 18 years of age (have valid government ID), and confirm that obtaining this service is a choice I made of my own volition. *

I am over 18 years old and am receiving this service voluntarily

Required

I agree to release and hold harmless Tiger Lily Collective LLC and its representatives from any damages, claims or legal actions arising from or in any way connected to the tattoo or other services rendered. *

I agree

Required

I acknowledge that allergic reaction or infection is possible, particularly in the event that proper aftercare is not followed. I agree to take care of the area treated to the best of my ability and strictly adhere to the aftercare instructions provided. *

I agree

Required

I acknowledge that by typing my full name below, this is considered a legal and binding document, and I agree to the terms and have honestly answered the items described in this form: *

Send me a copy of my responses.

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