Microblading Form
Medical Consultation for Microblading
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
-
Day
-
Month
Year
Date
List any medication you are currently taking (up to 6 month) If none state N/A
*
Are you Currently under care of a doctor or hospital specialist?
*
Yes
No
If yes, Please provide relevant information including Doctor's details
Do any of these apply to you?
*
Contact Lenses
Glasses
Eye Condition
Eye disease
Cold Sore
Pregnant
Hyper Pigmentation
Scar Tissue
Keloid Scarring
Haemophilia
Diabetes
Hepatitis
TB or Lung Disease
Chemoptherapy
Radiation
Infectious Disease
Cancer
Lupus
HIV Positive
Venereal Disease
Asthma
Iron Deficient
Anaemia
Skin Disorder
Mitral Valve Prolapse
Herpes Simplex 11
Dry Eye Syndrome
Alopecia
Epilepsy
Fainting/Anxiety/Panic Attacks
None of the above
Have you recently undergone, or planning to undergo any elective or necessary surgery? If Yes Please give details.
*
Are you allergic to any of the following?
*
Latex
Lanolin
Vaseline
Medication
Metals
Hair Dyes
Foods
Lidocaine
Paints
Crayons
Glycerine
Plasters
No allergies
Are you taking any medication that thins the blood?
*
Yes
No
Are you taking any of the following medication?
*
Accutane
Insulin
Steroids
Antabuse
Aspirin
Anti-coagulant
Blood Pressure meds
Herbal remedies
None of the above
Have you had or planning to have any injectables, fillers, chemical peels or laser skin treatments?
*
Yes
No
If Yes, please provide details/dates.
Do you suffer from or have problems with scar/wound healing?
*
Have you had a patchtest? Was the outcome reactive or non-reactive ?
*
Date of Patchtest
*
-
Day
-
Month
Year
Date
Date
*
-
Day
-
Month
Year
Date
Signature
*
Submit
Should be Empty: