Studio Mae

Intake

This form completes your treatment file. We only ask what is needed to treat you safely. Your answers go directly to the studio and nowhere else, and are kept according to the retention period in the privacy statement.

Which session is this?

Name *

E-mail address *

Phone number *

Date of birth *

Address *

Desired treatment *

Have you had this treatment somewhere else before?

Health

Answer every question with yes or no. A yes does not automatically mean the treatment cannot go ahead; we discuss it together.

Are you pregnant or breastfeeding?

Do you have haemophilia or another clotting disorder?

Are you currently taking blood thinners or antibiotics?

Do you have diabetes?

Do you have a heart or vascular condition?

Do you have epilepsy?

Do you have an autoimmune condition or a weakened immune system?

Do you have a skin condition on the treatment area (eczema, psoriasis, infection)?

Is there a mole or scar on the treatment area?

Are you prone to keloid scarring?

Do you have allergies (latex, metal, pigment, anaesthetic)?

Have you had a laser treatment, peel, Retin-A or Botox on the treatment area in the past 4 weeks?

Have you had PMU on this area before? If yes: when and where, and bring a photo.

Have you had chemotherapy or radiation in the past 12 months?

Are you under a doctor's care?

Have you used alcohol or drugs in the past 24 hours?

Is there anything else I should know?

I declare that I have read the information about the treatment, that I understand the risks, that I am not under the influence of alcohol or drugs, that I understand the aftercare instructions, and that I have filled in this form truthfully. Read more here.

I have read and understood the information about the treatment, healing and aftercare, and consent to the treatment. Read more here.

I give explicit consent to keep the health details from this form for my treatment file, 5 years after my last treatment. Read more here.

Photos of my treatment may be used anonymously for portfolio and social media.

I would like to receive occasional tips and news by e-mail.

Signature

Full name (typed) *

Date: 16/09/2026