Topical Anesthetic
Physician Letter Request Form
Your Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email
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Confirmation Email
example@example.com
Phone Number
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Please enter a valid phone number.
Medical History Questions
1a. Do you have any known allergies to lidocaine, tetracaine, benzocaine, or other '-caine' anesthetics? Or, have you had any adverse reactions to numbing creams or dental anesthesia? If yes, describe below.
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Yes
No
This is my first time using a numbing cream/agent
1b. Describe your response to Question 1a.
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2a. Do you have ANY of the following conditions: heart problems or irregular heartbeat; liver disease; kidney disease; anemia, blood disorders, or history of methemoglobinemia? If yes, describe below.
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Yes
No
2b. Describe your response to Question 2a.
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3a. Are you pregnant or breastfeeding? If yes, describe below.
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Yes
No
3b. Describe your response to Question 3a.
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Please know that you are not able to undergo a permanent makeup service while pregnant or breastfeeding
4a. Are you currently taking any prescription or over-the-counter medications? Or, are you using any topical creams or ointments on the area to be numbed?
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Yes
No
4b. Describe your response to Question 4a.
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5. Please list any other medical conditions that could influence the safety or effectiveness of a topical anesthetic.
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I certify that the information provided above is true, accurate, and complete to the best of my knowledge. I understand that any inaccurate or omitted information could affect the safety or appropriateness of using a topical anesthetic product.
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I authorize the secure digital transmission of my health information as necessary to obtain physician approval for topical anesthetic use. I understand that my information and physician’s letter may be shared with my permanent makeup provider for treatment coordination.
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I agree to receive updates and communication by email or text. Standard message or data rates may apply.
Signature
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Date
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Month
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Day
Year
Date
Submit
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