Confidential Medical Profile- Micropigmentation

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Are you under 18?

If so, guardians initials

Have you had any aspirin or blood thinners in the past week?

Any mood altering drugs within the last 8 hours?

Do you have a history of cold sores, herpes, or fever blisters?

Are you sensitive/allergic to latex?

Have you had a chemical peel or laser?

If so, when?

Do you have problems healing?

Are you currently undergoing radiation or chemotherapy?

Are you currently using an retin-a or alpha-hydroxy skin care products?

Previous problems with tattoos or has your physician advised you not to have a tattoo at this time?

Are you allergic to any metal?

Have you ever had any semi-permanent makeup procedures before?

Are you on any immunosuppressive medications such as anti-inflammatories or steroids?

Are you allergic to topical antibiotic preparations or desensitizers?

Is there any history of skin diseases or remarkable skin sensitivities?

Are ypu currently taking any vitamins A or E in any form?

Are you pregnant or nursing?

Are you required to take antibiotics during dental or invasive medical procedures?

Do you wear contact lenses? ( If yes, I understand they must be removed during my eyeliner procedure and should not be replaced until the next day)

List all Medications:

Please Choose Any of the Following That Pertains To You:

List any other medical conditions or issues not addressed above:

PCP name

PCP Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

By signing below, I acknowledge, understand and agree that:

• the staff at Afrocenstry Beauty do not practice medicine, does not accept health insurance, and have madeno representation to the contrary;

• the information provided on this form is accurate and complete to the best of my knowledge, and thatAfrocenstry Beauty is not responsible for complications or problems arising from any incorrect or omittedinformation;

• some individuals will have complications related to semi-permanent makeup application. Thesecomplications are usually mild and last only a few days. However, extreme complications are always apossibility. I accept these risks and agree to hold Afrocenstry Beauty and its employees and contractorsharmless for same;

• the staff at Afrocenstry Beauty will use the information provided above to assess my suitability for theproposed micropigmentation services.

Signature

Date