This form provides us with important information about you, your health and your upcoming cosmetic tattooing procedure. We'll contact you once our pharmacist has reviewed your information and confirmed this medication is right for you.

Patient details

First name *

Surname *

Email *

Date of birth *

Phone *

Home address *

We need this to legally dispense your topical anaesthetic. We'll ship it directly to the clinic if selected.

Procedure - select all that apply *

New Salon Sample
Cosmetic tattooing - Lips
Cosmetic tattooing - Brows
Cosmetic tattooing - Eyeliner
Cosmetic tattooing - Areola
Tattoo - small area
Tattoo - large area
Tattoo removal - Laser
Tattoo removal - Non Laser
Micro-needling
Skin needling (no epinephrine)
Fibroblasting
Cosmetic treatments
Other

Procedure date *

Delivery options *

Send product to the clinic ($5 shipping)
Send product directly to listed address ($10 Shipping)
Collect product in store (No shipping cost) 10 Dallas parade, Keperra QLD 4054

Clinic details

Clinic name *

Clinic suburb *

Clinic post code *

Patient medical history

Are you taking any medication? *

Do you have any medical conditions (eg. heart rhythm irregularity)? *

Do you have any allergies or sensitivities (eg, local anaesthetic, egg or sulfur)? *

Are you currently pregnant or breastfeeding? *

Pregnant
Breastfeeding
Neither

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!