Inkd By Harman Pre-Appointment Intake Form
Consult Form + Medical History
Full Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Date of Birth
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Month
-
Day
Year
Date
I,
First Name
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Last Name
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am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive indicated Cosmetic Tattoo procedure.
Concerns with your current brows/lips:
*
Current Medications and/or Herbal Supplements:
*
Allergies to Medication or Food:
*
Previous Surgeries or Cosmetic Procedures:
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Have you used or have you had any of the following:
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Botox in the last 4 weeks
Accutane
Laser Resurfacing
Sunburn on your face
Retin-A Burns
Liposuction on your face
Chemical Peel
Photo-Derm Skin Grafts
Intense Light Glycolic Acid
None of the above
If yes please provide date and on which area:
Do you have or had any of the following:
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Injectable fillers in the last 6 months - Brow Area
Currently Pregnant and/or breastfeeding
Menopause
Hormone Imbalance
Latex Allergy
Problems with Healing
High Blood Pressure
Bleeding Disorder
Dermatitis/Eczema
Cancer
Cold Sores/ Herpes
Diabetes
Heart Condition/Pacemaker
Hepatitis
HIV
Hemophilia
Keloid Scars
Allergy to Red Lake 5
Hyper Pigmentation
Any active infections
Smoker
None of the above
Other
Are you currently under the care of a physician for management of an illness or condition?
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Yes
No
I,
First Name
*
Last Name
*
, acknowledge that all the above information contributed by me is true and accurate to the best of my knowledge.
Please abide by the following Pre-care procedures Please check next to each entry :
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No Alcohol 24 hours prior to your appointment.
No Aspirin, Ibuprofen, Vitamin E, 24 hours prior to your appointment.
No Caffeine or alcohol 24 hours prior to your appointment.
No strenuous workouts the day of your appointment.
No tanning the day of your appointment.
For lips, please take antiviral medication for cold sores if needed and scrub lips daily for 5-7 days and wear chapstick daily.
No Botox in your brow area or lip fillers at least 3 weeks prior to your appointment.
During the first 10 days after treatment, I WILL Follow the Aftercare below Please check next to each entry :
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Avoid direct exposure of the treated area to UV rays (Sun or Tanning beds)
Apply the provided aftercare ointment with a cotton swab every 2-3 hours or as needed. Do not use other products on the treated area other than what is provided to you.
No water, cleansers, creams, makeup, rough towels, and other products, etc... on the treated area.
Do not soak the treated area in water. You can shower as normal but keep the area out of the shower spray as much as possible. Do not let the area stay wet for more than a few minutes.
No baths, swimming, saunas, hot tub, steam rooms, hot yoga, etc....
Do not touch, rub, pick or scratch the treated areas. Let any scabbing or dry skin exfoliate off naturally. Picking can cause scaring.
For lips, keep them clean. No kissing or eating spicy foods. No picking scabs. Apply ointment provided every 2 hours and clean lips regularly.
Avoid heavy/excessive sweating
No facials, brow tinting, tweezing, waxing, threading
Avoid sleeping on your face
Visible healing will take up to 10 days, it is perfectly normal for your treated brow area to scab. The scabs will fall off within a few days. It is normal for the color to appear darker in the first couple of days, and then fade during the two weeks following the treatment.
For 4 WEEKS after my Treatment I will not have any of the following: Please check next to each entry
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Botox
Injectable Fillers
Chemical Treatments
Microdermabrasion
Signature
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Date
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Month
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Day
Year
Date
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