Call Michelle: (941) 348-1933

Paperwork

Download insurance documents below, or select Complete Client Paperwork to fill out and submit your form online.

Download Client Insurance Guide (PDF)
Download Doctor’s Letter Template (PDF)
Complete Client Paperwork
Page 1 of 3

CLIENT HISTORY FORM

Location of Service: 623 N LIME AVENUE
SARASOTA, FL. 34237

Select Yes or No for each question. When you select Yes, enter your explanation in the box that opens below that question. Your explanation and question number will copy automatically to the medical log on page 2. Also list any other medical condition or information you want the artist to be aware of. Please answer accurately. The information is used to help the artist decide the proper technique and formulas for the client.

Use your finger or mouse to sign in the box.

Draw your signature above.
Page 2 of 3

MEDICAL LOG

Record the question number, date, and explanation. Include medications and other information you want the artist to know.

RETURNING APPOINTMENT

Returning clients only: I agree that all paperwork filled out on the date below is accurate and applies to today’s appointment. Please tell the artist and adjust the medical log if anything has changed since your last appointment.

Use your finger or mouse to sign in the box.

Draw your signature above.
Page 3 of 3

Cosmetic Tattoo Consent Form

Please carefully read and check each box to acknowledge and agree to each statement.

If you request a test patch, we recommend having it performed by a licensed allergy specialist. Schedule testing before your tattoo appointment and allow extra time, as results may take longer than expected.

Use your finger or mouse to sign in the box.

Draw your signature above.

Insurance Billing Assistance

Clients with Aetna, Cigna, or Meritain Health can contact Medical Tattooing Billing Services (MTBS) to discuss their plan and possible insurance billing assistance. MTBS must confirm eligibility and any required approval steps before treatment.

Phone: (407) 982-4876
Email: claims@mtbs.ink
Website: www.mtbs.ink

Insurance Resources for Clients Paying Out of Pocket

These resources are for clients who pay SeaChelle’s, LLC out of pocket and wish to ask their insurance company about possible reimbursement. Reimbursement is not guaranteed. Before treatment, confirm your plan’s coverage, provider eligibility, prior authorization requirements, and claim documents and deadlines.

Client Insurance Guide

Use this one-page, fillable guide when you contact your insurer. Record their answers and ask what you will need to request reimbursement after paying out of pocket.

Medical Necessity Letter Template for Your Doctor

Give this template to your surgeon or treating physician. Your doctor must personalize it based on your medical history and clinical needs, then sign it. A medical necessity letter does not guarantee coverage or reimbursement.

Use the download buttons at the top of this page and save your own copy before filling it out. If you need assistance, contact Michelle at (941) 348-1933.

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