• Permanent Makeup- Client Medical Info

    Client Medical Health History Form
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  • Birthdate*
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  • Referred by:

  • SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):*

  • Cosmetic History

  • How would you describe this your skin?*
  • Have you had microblading or permanent makeup in the past?*
  • Do you have any scars in or around the area to be treated?*
  • Are you prone to keloid or hypertrophic scarring?*
  • Have to you ever had any of the following injectables or implants?*

  • Have to you had any other cosmetic surgeries/procedures?*
  • Have to you used Accutane in the past year?*
  • Do you use skin care products containing Retin-A, Glycolic Acid or Alpha Hydroxyl?*

  • Health History

  • Have you had chemotherapy in the past 6 months?*
  • Do you have any of the following conditions:*
  • Do you have any other health conditions, skin diseases, diseases or disorders not mentioned here?*
  • Do you have moles/skin growths in the area to be treated?*
  • Do you or have you had a piercing in the area to be treated?*
  • Have you ever had a reaction at the dentist or any other time from numbing?*

  • Have you consumed drugs or alcohol in the last 24 hours?*
  • Have you undergone surgery in the last 2 weeks?*

  • 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)

  • 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.

  • Should be Empty: