• Beauty Culture

    Client Medical History - Microblading
  •  -

  • Do you or have you had any of the following: (Click Yes or No)

  • Pregnant now- Breastfeeding*
  • History of MRSA*
  • Diabetes*
  • Cancer?*
  • Chemotherapy/ Radiation*
  • Hepatitis A, B, C, or D*
  • Heart Condition*
  • Taking any blood thinners?*
  • Autoimmune Disorder*
  • Alcoholism*
  • Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate?*
  • Any other known allergies?*
  • Botox*
  • Forehead/ Brow Lift*
  • Face lift*
  • Chemical Peel*
  • Brow or Lash Tinting*
  • Oily Skin*
  • Do you use skin care products containing Retin-A, Glycolic Acid, Alpha Hydroxy Acid, or Beta Hydroxy Acid?*
  • Accutane or Acne Treatment*
  • Do you use a tanning booth?*
  • Difficulty numbing with dental work?*
  • Are you currently taking any medications or herbal supplements?*
  • Any diseases or disorders not listed?*

  • All of the above information is true to the best of my knowledge:

  • Should be Empty: