PMU Medical History Form
Please take a moment to answer this form as accurately as possible.
Section 1 - Client Information
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Line 1
Line 2
City
County
Post Code
Occupation
Date of Birth
-
Month
-
Day
Year
Date
PMU is only for over 18 year olds. Please upload a valid photo ID to match your DOB and full name if you are under the age of 25. Note: this photo uploaded is used for verification and proof of age purposes only. You are more than welcome to block out the DL #.
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How did you hear about us?
*
Section 2 - Medical Questionnaire
Please take a moment to accurately answer this section
What is your skin type?
*
Dry
Normal
Oily
Combination
Do you have any blood borne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis (A,B,C,D) ?
*
Yes
No
Are you currently pregnant or breastfeeding? If yes, you must not be pregnant or nursing at the time of appointment.
*
Yes
No
Have you had Botox within the past 6 months in the brow/forehead area?
*
Yes
No
Have you had any surgeries including blepharoplasty (eyelid surgery) and/or forehead/brow lift?
*
Yes
No
Allergic reaction to any medications such as Lidocaine, Prilocaine, Epinephrine, Dermacaine, Tetracaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, macrogolglycerol hydrostearate etc.
*
Yes
No
Are you currently on any blood-thinning prescription drugs?
*
Yes
No
Please check all that applies to you:
Abnormal Heart Condition
Accutane/Prescription Acne Medicine within last 12 months
Allergy to Latex/Metals/ Antibiotics
Alopecia
Anemia
Autoimmune Conditions
Bruise of Bleed Easily
Epilepsy
Cancer
Circulatory Problems
Diabetes
Eczema (face)
Glaucoma
Glucose-6-phosphate dehydrogenase deficiency
Heart conditions, pacemaker, defibrilator (no exceptions)
Hemophilia
Herpes
High Blood Pressure
Keloid Scars
Low Blood Pressure
Methaemoglobinaemia
None of the above
Other Tattoos
Pregnant or nursing
Psoriasis (face)
Seizures
Sensitivity to Cosmetics
Suffer from Eye Infections
Thyroid conditions
Trichotillomania (compulsive pulling of body hair)
Watery Eyes
*Other
Any *other medical conditions you need to tell us about
Please list any medications you are taking
Please take or upload bright photos of your full face and separate photos of the area you want treated from various angles below. Up to 5 photos. (If you're unable to complete this, photos can be completed on the day).
Or photo upload
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Special requests, concerns or remarks for clinician:
*
I confirm that I have completed the medical questions to the best of my knowledge
Date
*
-
Month
-
Day
Year
Date
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