themedicaltattoo.com - Confidential Medical Intake Form

Confidential Medical Profile - Micropigmentation
Name:
Date Of Birth:

MonthDayYear
Date
Address:
To Avoid Unforeseen Complications, Please Answer The Following Questions

Medical History Questionnaire

Rows	Yes	No
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?
Do you have problems healing?
Are you currently undergoing radiation or chemotherapy?
Are you currently using any 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 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 you currently taking any vitamins or herbs in any form?
Are you pregnant or nursing?
Are you required to take antibiotics during dental or invasive medical procedures?

Are you under 18?
If so, guardians initials
Have you had a chemical peel or laser?
If yes, when?
Do you wear contact lenses? (If yes, I understand they must be removed during my eyeliner procedure and should not be replaced until the following day.)
List all medications you are currently taking
Please Check Any Of The Following Which May Pertain To You
List any other medical conditions or issues not addressed above
Primary Physician’s Name
Primary Physician’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Location of Treatment
By signing below, I acknowledge, understand and agree that:
- the staff at The Medical Tattoo do not practice medicine, does not accept health insurance, and have made no representation to the contrary.
- the information provided on this form is accurate and complete to the best of my knowledge, and that The Medical Tattoo is not responsible for complications or problems arising from any incorrect or omitted information;
some individuals will have complications related to semi-permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold The Medical Tattoo and its employees and contractors harmless for same;
- the staff at The Medical Tattoo will use the information provided above to assess my suitability for the proposed micropigmentation services.
Client signature (or guardian if under 18 years of age)
Date

MonthDayYear
Date
The Medical Tattoo | 13840 Box Turtle Loop, Parker, CO 80134 | 303-621-4711
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Confidential Medical Profile - Micropigmentation

To Avoid Unforeseen Complications, Please Answer The Following Questions