Medical Consult

Medical Consult

Jesse Volpato, Bella Esthetics & Micropigmentation 303045 AB-806, Linden, AB, T0M1J0
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Leave boxes empty if they do not apply.
contact lens (must be removed for eye treatments)
dry eyes
cold sores/herpes This only applies to Lip Blushing. Please see your Dr and begin taking Valtrex four days before your appointment, the day of, and 5 days after.
blurred vision
glaucoma
cosmetic injections (lip fillers)
chapped lips
pregnant
high blood pressure
other eye disorder
alopecia
thyroid
botox, derma fillers
laser vision correction
allergy to topical anesthetic
bruise easily
auto immune disorders
blepharoplasty, eye lift
latex allergy
hepatitis (please state type)
HIV
using Latisse or lash growth
Do you use Retin A, Hydroxyl(glycolic) acid?These products will fade tattoos.
existing cosmetic or body tattoos
treated for depression
Are you using blood thinners/anticoagulants, aspirin, ibuprofin, coumadin?
Are there any other areas of concern?
list medications
Do you have any serious medical concerns not outlined above?
Do we require a physician's note? This may apply to those with diabetes or skin conditions (must be on letterhead or RX)
On a scale of 1-10 (10 being the most satisfied) how happy are you with your physical appearance?
Please note the following: 1. If you have checked the "cold sore" box and are having a lip tattoo, you must be on an antiviral prescription such as Valtrex before and after treatment. 2. If you are currently using "Latisse" or any lash growth serum on lashes/brows, you may experience more sensitivity to tattoos, you must discontinue using a minimum of 2 weeks prior. 3. There are no specific guarantees of any kind with regard to individual retention of tattoo pigment in the skin. Fading and retention will vary from client to client, and in no way will the technician be held responsible for the difference in the healed results, although every attempt will be made to complete the original procedure to the best of the technician's ability. 4. Corrections to a previous tattoo done elsewhere may be subject to an additional charge as deemed by the technician.
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