Client Intake Form

Please take a few moments to complete the required forms below prior to your scheduled appointment. Completing these in advance allows us to review your health history, tailor your session to your specific needs, and dedicate your entire appointment time to your care.

First name

Last name

Date of Birth

Month

Day

Year

Phone

Please upload a picture of your Driver's License

Please complete this informed consent by checking the boxes next to each statement.

Client is voluntarily obtaining services of their own free will and volition.

Client has had the opportunity to read and understand the documents (paper or digital) presented.

Client has the ability to ask questions about procedure.

Client has received and understands written and verbal aftercare instructions.

Client agrees to allowing photographs and or videos of procedure and use for marketing purposes and on social media platforms but not limited to.

Emergency Contact

Are you currently under the treatment with a Physician? If so, please list reason and the contact information for the Physician.

List all medications and any Supplements, vitamins, Peptides, etc. Note: If any of these medications, etc. may interfere with blood clotting or which may thin the blood, are Anticoagulants (ex: Aspirin, Arfarin, Plavix, etc.) Please circle them.

Client should consult a physician prior to procedure if they have any concerns related to conditions. Health conditions listed may increase health risks associated with receiving a body art procedure. Please check box if you understand.

Do you have any medical conditions that require you to pre medicate with antibiotics (even dental procedures)?

Yes

Do you have a history of diabetes or any disorder or medication that affects the neurological or immune system in fighting infections? (May heal slowly and need more touch ups.)

Yes

Have you been diagnosed with any Bloodborne conditions such as Hepatitis B, Hepatis C, HIV, AIDS?

Yes

Have you experienced Jaundice in the past 12 months?

Yes

Have you been diagnosed with Anemia? (Iron deficiencies can heal very light and possibly need more touch ups)

Yes

Do you have a history of hemophilia or any other blood clotting abnormalities?

Yes

Do you menstruate?

Yes

If so, next cycle date:

Are you pregnant or nursing (No Tattooing or Paramedial Pigmentation allowed)?

Yes

Have you been pregnant in last 3 months?

Yes

Do you have a history of seizures, seizure related condition(s), epilepsy, fainting, Syncope, POTS, or Narcolepsy?

Yes

Do you have any known Heart Conditions or pacemakers or medical implants?

Yes

History of stroke or heart attack?

Yes

Have you been diagnosed with any Autoimmune disorders?

Yes

Are you under treatment for Depression, Anxiety, or medical conditions?

Yes

Do you have breast implants or other non-medical implants?

Yes

Have you had elective or non-elective surgeries in past year?

Yes

Do you have any bleeding disorders or diagnosed as a Hemophilic?

Yes

Do you have problems healing?

Yes

Are you now or have you ever been on acne treatment, Accutane? If so, you will need a medical release from your Physician with last day of medication. (Please note: You must be off Accutane for a minimum of 3 months.)

Yes

Do you have a personal history of Cancer?

Yes

Are you currently undergoing radiation or chemotherapy? Have you ever? (Please note: you will need a medical release from Physician, waiting period usually 6-12 months after radiation or chemotherapy with white blood count returned to normal.)

Yes

Do you have a history of skin disease(s), skin lesions, or history of keloid?

Yes

Do you have a history of allergies or adverse reactions to pigments, dyes, ink, or other skin sensitivities?

Yes

Have you been diagnosed with Mast cell activation syndrome?

Yes

Do you have a history of or suspicion of adverse reaction to latex or products containing latex? (Please note: The Healing Hands of Woodstock, LLC uses gloves free of latex)

Yes

Do you have an iodine allergy?

Yes

Are you allergic or sensitive to any metals? (Metals used for jewelry)

Yes

Are you sensitive to petroleum-based products or Vitamin E?

Yes

Are you allergic to Vitamin C?

Yes

To your knowledge are you allergic or resistant to over-the-counter numbing products?

Yes

Have you ever had a tattoo or permanent cosmetics?

Yes

If yes to last question, Did you have any problems healing?

Yes

Do you intentionally tan?

Yes- Sun

Yes- Tanning Bed

Please note: As per the “After Care Instructions, you will be required to keep pigmented skin out of the sun and tanning beds for a minimum of 4 week after “last procedure”. After you will be required to apply sunscreen. Direct sun exposure may slow skin healing and cause the need for more sessions due to fading). If you understand please check the box.

Do you scar easily?

Yes

Do you Hypo-pigment? (scars turn white after healing)

Yes

Do you Hyper-pigment? (scars that turn dark after healing)

Yes

Do you tend to develop keloids or hypertrophic scars? (Raised or bubbled scars)

Yes

Have you eaten in last 4 hours?

Yes

Have you had any alcohol in the last 24 hours? (May cause increase sensitivity, bleeding and extended healing time. Possibly more sessions will be needed)

Yes

Do you use tobacco? (Please note that smokers tend to heal slower and may need longer time in between follow up appointment(s), more sessions may be needed.)

Yes

Are you under the influence of any drugs?

Yes

NOTE: Clients under the influence of drugs or alcohol will not be treated and will need to reschedule with a $100 rescheduling fee. If any deposits were made they will not be refunded.

Waiver & Release

I hereby waive and release, indemnify, hold harmless and forever discharge The Healing Hands of Woodstock, LLC Jessica Robin Crothers and it's employee(s) from any and all claims, demands, expenses, lawsuits, liabilities and damages, of every or any kind and nature that I ever had or may have, arising from or in any way related to the services or procedures being provided to me the client by The Healing Hands of Woodstock, LLC Jessica Robin Crothers provided that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct. Said services may include but are not limited to Paramedical Pigmentation, Medical Pigmentation, 3D Areola Restoration, Areola Restoration, Scar Camouflage, Stretchmark(s) Camouflage, Vitiligo or Hypopigmented skin Camouflage, Tattoos. By this waiver, client understands and assumes any risk, and takes full responsibility and waives any claims of personal injury, death or damage to personal property associated with such services provided by The Healing Hands of Woodstock, LLC Jessica Robin Crothers including but not limited to temporary or permanent damage to skin, mental or emotional health, unsatisfactory results from the said services or procedures being provided to client. This Waiver and Release contain the entire agreement between The Healing Hands of Woodstock, LLC Jessica Robin Crothers and myself, and supersedes any prior written or oral agreements concerning the subject matter of this Waiver and Release. The provision of this latter will continue in full force and effect even after the services/procedures being provided to me. I have read, understood, and fully agree to the terms of this Waiver and Release. I also understand by signing this form, I have given up considerable future legal rights. I have signed this agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. I am 18 years of age or older and mentally competent to sign this Waiver and Release. I am not under the influence of any drugs, alcohol, pharmaceuticals drugs that may alter thoughts or decisions, or any other substance that can alter a person’s thought process or ability to understand this agreement.

Patch Test Consent

Patch Testing involves placing small amounts of Ink/Pigment into the skin and monitoring for 48-72 hours. The testing site is then monitored for local reaction. Potential adverse events include rash at the site, infection, or delayed skin reactions.

There is a possibility of an allergic reaction to pigments. Pigments may or may not contain iron oxide, titanium dioxide, isopropyl alcohol, propylene glycol, glycerin, ethanol, distilled water, and witch hazel.

A patch test is advisable however it does not ensure a client will not have an allergic reaction.

Please choose:

I CONSENT THE PATCH TEST: By receiving a patch test on the date below, I release The Healing Hands of Woodstock, LLC and Jessica Robin Crothers from liability for any present or future allergic reactions or complications related to tattoo/permanent makeup pigments, including those triggered by sun exposure or improper post-care.

I WAIVE THE PATCH TEST: I release The Healing Hands of Woodstock, LLC and Jessica Robin Crothers from any liability if I develop an allergic reaction to tattoo or permanent makeup pigments during or after the procedure.

Media Release

Authorization to Record for Marketing purposes, Social Media, Advertising, Portfolio, Educational purposes (But not limited to)

I hereby authorize The Healing Hands of Woodstock LLC, Jessica Robin Crothers and employees or hired professionals to capture, record, and use digital photographs, video recordings, audio recordings of my treatment(s) along with sharing any testimonies or reviews publicly.

Anonymity & Privacy Preferences

The Healing Hands of Woodstock LLC will do their best to only share the areas of the body being treated and will try their best to keep your face from being in shared material. Exceptions are if treatment is above chest area or if the client is giving a recorded testimony. The Healing Hands of Woodstock cannot guarantee that your face will not be in any recording.

Purpose, Scope, and Healing Stages

I understand that these recordings will be used for marketing, educational portfolio, social media, and promotional purposes. This authorization permits The Healing Hands of Woodstock LLC to publish any and all recordings. Including any recording taken and shared by the client (usually progress and after photos but not limited to).

Rights & Acknowledgments

By signing below, I explicitly acknowledge and agree to the following terms:

● Voluntary Participation: Signing this form is completely voluntary.

● Right to Revoke: I have the right to revoke this authorization in writing at any time by contacting the Practice in person and signing a document of Right to Revoke. Revocation will stop future distribution but cannot retract media already published or shared online.

● Risk of Redisclosure: I understand that once my images are published on public social media platforms or websites, they can be shared or downloaded by the public.

● Expiration: This consent does not have an expiration date.

Signature and Affirmation

I affirm that I am at least 18 years of age. I affirm that I am the client receiving these services. I have read this document completely and agree to all its terms. I am not under the influence of any drugs or alcohol. I fully understand when writing a testimony or any review, the way I write the testimony or review will be shared. If you do not want your name and want to remain anonymous, please do not add it to testimony or review.

Model Consent

1. Portfolio Building and New Artist Acknowledgment: The Model understands and acknowledges that the Artist is new to the industry and is building their portfolio. The Model agrees to participate in this treatment with the understanding that it is part of the Artist's professional development and portfolio building process.

2. Free Treatments In exchange for the Model's participation, the Artist agrees to provide the treatment(s) free of charge. The Model agrees that in return for receiving these complimentary treatments, they will provide the Artist with royalty-free rights to all photos and videos taken during or after the treatment(s). The Model understands that these materials will be used for the Artist's portfolio, promotional materials, social media, website, and other marketing purposes. Model agrees to send follow photos during the healing process and agrees to complete all needed sessions for optimal results.

3. Use of Likeness: The Model hereby grants the Artist and their representatives the irrevocable right and permission to use, reproduce, edit, publish, and distribute any photos, videos, or other media that feature the Model's likeness, image, and appearance. This permission is granted for all purposes related to the Artist's business, including advertising, promotion, and portfolio display, without any further compensation or approval required from the Model.

4. Release of Liability: The Model acknowledges that their participation in the treatment(s) is entirely voluntary. The Model agrees to assume all risks associated with the treatment(s), including any potential side effects or complications. The Model releases and holds harmless the Artist, their representatives, and any affiliated entities, the trainers and manufacturers of the products, from any and all liability, claims, demands, or causes of action that may arise from the treatment(s) provided, including but not limited to personal injury, property damage, or any other losses incurred as a result of the Model's participation.

5. Voluntary Participation: The Model confirms that their participation in the treatment(s) is completely voluntary and that they have not been coerced, pressured, or otherwise influenced to participate. The Model agrees that they are participating of their own free will and that they have had the opportunity to ask questions and seek clarification about the treatment(s) before agreeing to participate.

6. Age Verification: The Model confirms that they are of legal age to consent to the treatment(s) and to enter into this Agreement. The Model represents that they are at least 18 years old. If the Model is under 18, a parent or legal guardian must sign this Agreement on their behalf.

7. Entire Agreement This Agreement constitutes the entire understanding between the Artist and the Model regarding the subject matter herein. Any amendments or modifications to this Agreement must be made in writing and signed by both parties.

8. Governing Law This Agreement shall be governed by and construed in accordance with the laws of the State of Georgia Cherokee County, without regard to its conflict of laws principles.

Please Note: The owner of The Healing Hands of Woodstock LLC has the right to terminate continued sessions or treatments if Model does not comply with the agreements and aftercare.

Model Consent

I consent.

I do not wish to be a model.

Signature

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Date and time

Month

Day

Year

Time

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Client Intake Form

Waiver & Release

Patch Test Consent

Media Release

Model Consent

Contact

Business Hours

Cancellation Policy

Legal