Microblading- Client Medical Info

Physician Contact Info:*

Have you had chemotherapy in the past 6 months?*

YesNo

Do you have any of the following conditions:*

Do you have any other health conditions, skin diseases, diseases or disorders not mentioned here?*

YesNo

If yes, please list:

Do you have moles/skin growths in the area to be treated?*

YesNo

Do you or have you had a piercing in the area to be treated?*

YesNo

Have you ever had a reaction at the dentist or any other time from numbing?*

YesNo

Do you have any allergies to medications, food, latex, topical products, and/or other substances? Please list:*

NoOther

Have you consumed drugs or alcohol in the last 24 hours?*

YesNo

Have you undergone surgery in the last 2 weeks?*

YesNo

Please be advised that if you are on any of these medications, you will bleed and the pigment may not retain:

Trifusal (disgren)
Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brillinta)
Ticlopidine (Ticlid)
Cilostazol (Pletal)
Voapaxar (Zontivity)
Dipryidamole (Persantine)
Coumadin
Pradaxia (Dibigatran)
Xarelto (Rivaraxaban)
Eliquis (Apixaban)
Savaysa (Edoxaban)
Thyroid Medications (problem with pigment retention)

Please list all vitamins and supplements including herbal remedies you take regularly:

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly:

What are you hoping to accomplish through this permanent makeup procedure?*

Is there anything else you would like us to know?

Practitioner makes no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent makeup application. These complications are usually mild and last only a few days. However, extreme complication are always a possibility. If you are healthy and there are no visible reasons restricting you from receiving a tattoo, you must approve of the design and color before the application of your permanent makeup.

I certify that the preceding medical, personal and skin history statements are true and correct to the best of my knowledge. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. *

I hereby release the practitioner and/or any of the practitioners associated from any and all claims, which I may now, or in the future arising from the tattooing process. I understand that the application of tattooing is artistic in nature and in all cases experimental and that no result can be guaranteed or certain. The tattooing process has been explained to me and I have been fully informed of the procedures to be performed. I execute this release having read and full understand it, and do so completely voluntarily. *

I grant permission for my photos to be used for commercial reasons and to be filed for insurances purposes. *

Initial

Permanent Makeup- Client Medical Info

Cosmetic History

Health History