cathi.ink corp Permanent Cosmetics Contact Form
Info on this form is privacy protected
The only person receiving and viewing this form is fine artist and CEO, Cathi Locati. Information you provide is never shared with anyone, ever. Upon submission of this form, a HIPPA protected file is created for you at cathi.ink corp and maintained throughout your Micropigmentation process. Thank you for your trust. Required fields must be filled in to create the best picture of you for your consultation with Cathi.
New client Name
What is your ethnicity / nationality?
For ink matching purposes, please select from the dropdown, if other...please describe below.
other - please describe
Describe OTHER ethnicity
SCHEDULE your free first consultation with Areola Architect Cathi Locati
Cathi will make every effort to reach you on one or the other dates and times you list below. If she is unavailable to schedule your first consultation at either of those times, she will call you during the best part of the day when you might be available...
Morning / Afternoon for Intake Session?
What is the best part of the day to reach you in general?
Mornings Monday through Friday
Afternoons Monday through Friday
First choice date to call you to discuss form:
1st choice time to call:
Second choice date to discuss form:
2nd choice time to call:
Who may we thank for referring you to us?
who referred you?
If you used Google to find cathi.ink...
which key words, phrases did you use? What path did you follow to find the website?
cell phone #:
Second number other than cell, home # or family #
City where you live
State you live in
Date of Birth
Your current age
Current medical condition:
I am in great physical condition
I am in good, ok physical condition
I am still recovering from surgery(s) and not quite 100% yet, but feeling ok
I am not feeling like I am in good physical condition
I am not in good physical condition yet
In your own words - what do you seek?
Ready, set, go?
Please indicate if are you ready for Micropigmentation now within the next week or two. If you are not ready yet, please indicate a time in the future when you feel you will be ready.
What is your NATURAL hair color?
What is the condition of your skin?
Do you have a regular tattoo?
If you have a regular tattoo...
did you have any adverse affects from it? Did you experience any issues with rashes or other problems? Please explain:
Do you have diabetes?
If you have diabetes....
please provide the name and contact info of your primary care provider for a medical release:
Please select Micropigmentation service:
Permanent Cosmetics of the brow
Permanent Cosmetics of the upper lip - liner only
Permanent cosmetics of the lower lip - liner only
Permanent Cosmetics of the lips both upper and lower - liner only
Permanent Cosmetics of the lips with fill: both upper and lower lined and fully filled with color
Select additional service:
cathi.ink Areola Procedure
cathi.ink Areola Procedure with scar camo (breasts) for scars outside of the areola perimeter
cathi.ink Areola Procedure REPAIR to fix damaged breasts from previous surgery
Scar camo only (breasts)
Decorative Mastectomy Cover Tattoo
7th Dimension Illusion BreastmoundsTM
7th Dimension Boustier
OTHER - please explain at end of form, last field
Attach photos of face
If you would like Cathi to review your current situation for assessment, using the file attachment upload link below this question, attach a clear, sharp focus photo of your face, eyebrows.
Anything else you would like to add?
You have created a client portrait for Cathi to best understand the picture of you during your consultation session over the phone. Cathi is looking forward to speaking with you about gorgeous full-color fine art solutions in permanent ink that will last forever. Cathi will call you asap once you have submitted this form.
Send me a copy of my responses
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