Scalp Micropigmentation (SMP) Pre-Consultation Form

Name *

First Name

Last Name

Phone number *

(###)

###

####

What is your preferred method of contact?

Ink Tricks will reach out to make an appointment for a consultation.

Email

Phone

Do you have Type 1 or Type 2 diabetes? *

YES

NO

Do you have an oily scalp (noticeable shine or build-up shortly after washing)? *

YES

NO

Have you taken Accutane (Isotretinoin) in the past 6 months? *

YES

NO

Are you currently pregnant, nursing or have given birth within the last 12 months? *

YES

NO

Are you currently taking and blood thinners? (e.g. Aspirin, Warfarin, Plavix, Eliquis?) *

YES

NO

Do you have any medical conditions, skin disorders, or scalp issues we should know about? *

YES

NO

Have you had SMP done before? *

YES

NO

-------Consent and Acknowledgment------ *

By submitting this form, I confirm that: * The information I've provided is accurate to the best of my knowledge. * I understand that this is a preliminary screening and does not guarantee candidacy for SMP. * I agree to be contacted by Ink Tricks Cosmentic Tattooing for further consultation.

I agree and consent to the above.