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Client Pre-Screen Form

Please fill out this information to the best of your ability. Don't hesitate to ask us to clarify anything if you are unclear. Be as honest as you can because we need accurate information to make sure we can provide you with the best service tailored to your body & health.

Health & Medical Pre-Screen

This form is confidential and judgement-free

First Name

Last Name

Email

Date of Birth

Phone

Pronouns

Instagram @ (optional)

Emergency Contact Full Name / Pronouns

Emergency Contact Phone Number

Emergency Contact Relationship

Are you pregnant or nursing? *

No

Yes

Do you have any current medical condition, illness, or injury? *

No

Yes

Do you have any allergies? *

No

Yes

If you answered yes to any of the above, please elaborate:

Do you experience any skin conditions?

None

Rashes / Hives

Scars

Stretch Marks

Eczema

Dermatitis

Freckles/Moles

Psoriasis

Other

List ALL medications / supplements you have taken in the past 7 days:

Have you ever been tattooed before? *

No

Yes

Have you ever experienced any reaction to the process, ink, or have any issues during healing? If so, please explain.

Do you have any concerns (physical or emotional) about getting tattooed?

Do you have any areas of your body that are physically or emotionally uncomfortable to receive touch?

When was the date of your last Accutane treatment?

Have you ever been prescribed Accutane?

Yes

No

Have you had botox within the past 2 weeks?

Yes

No

What is your skin type?

Oily

Dry

Combination

Do you smoke tobacco?

Yes

No

COVID-19 QUESTIONS

Have you experienced any symptoms of COVID-19 or illness in the past 14 days? (coughing, sneezing, wheezing, congestion, fatigue, headache, nausea)

Yes

No

Have you traveled outside of the USA or had close contact with anyone that has traveled outside of the USA in the past 14 days?

Yes

No

Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?

Yes

No

Would you prefer that our staff remains masked at all times?

Yes

No Preference

For everyone's health and safety,

Our staff is vaccinated and boostered.
If you want a fresh mask we can provide you with one.
Hand sanitizer is also made available in each room for your convenience.

I confirm that ALL the info I’ve provided is accurate & complete

I understand that based on my answers, there may be certain precautions taken to ensure that the health and safety of myself and others are prioritized, this may include (but not limited to) cancelling or rescheduling the appointment, or possible alterations to the tattoo and aftercare process to fit my needs.

Your Signature

Thanks for submitting!

347-542-4154
hi@reveriebk.com

© 2022 Kae Gabrielle x Reverie

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