Alchemy Intake

Medical/Intake Questionnaire
Full Name*

First NameLast Name
E-mail Address*
example@example.com
Contact Number*
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Date of Birth

DayMonthYear
Do you understand that you must avoid Botox in the procedure area 2 weeks prior to your scheduled session?*

YesNo
Do you have any complications with healing? Diabetes, Eczema, Psoriasis, Sunburn, Keloids or Hypertrophic scarring in the procedure area?*

YesNo
Please provide details.
Are you pregnant or currently breast feeding?*

YesNo
Have you used Accutane in the last 12 months?*

YesNo
Are you currently undergoing Chemotherapy?*

YesNo
Please provide details.
Have you had any surgery in the past 30 days?*

YesNo
Please provide details.
Other medical history you would like to share?

YesNo
Please provide details.
Are you currently prescribed or taking any blood thinning medications the day of your procedure including ibuprofen and/or fish oil?*

YesNo
Are you able to sit and/or lay on your back for at least 2 hours?*

YesNo
Can you avoid alcohol and/or caffeine 24 hours prior to your procedure?*

YesNo
Are you able to follow aftercare instructions provided?*

YesNo
Please explain your desired results from the selected procedure. Please text or email us a well lit, front facing photo (not in selfie mode) for all Permanent Makeup procedures. *
Should be Empty:

Medical/Intake Questionnaire