MICROPIGMENTATION CLINIC CLIENT MEDICAL FORM
Name: _________________________________________________ D.O.B. ________________ Address:_____________________________________________________ P/Code _________ Home Phone: ________________________ Business Phone: __________________________ Email: _______________________________________________________________________ May we contact you at these numbers? Y / N Mobile No. _______________________________ Referred by: __________________________________________________________________ Emergency Contact: ______________________________ Phone Number: ________________ Procedure(s) desired: Upper Eyeliner
Other: ______________________________________________________________ ALLERGIES: Check if you have ever had an allergic reaction to any of the following and describe what happened below. ________________________ Lanolin
________________________ Bacitracin Ointment _______________________ Novocaine ________________________ PABA
_______________________ Neomycin or polymyxin B
________________________ Other Allergies: __________________________________________ Reaction: _________________________________________________________________________________ __________________________________________________________________________________ EYES / EYEBROWS: Check all of the following that apply. _____________________ Contact Lenses
____________________ Eye makeup sensitivities
_____________________ Thyroid abnormalities ____________________ Alopecia Universalis (total) _____________________ Glaucoma
____________________ Alopecia Areata (local)
_____________________ Other hair loss, describe: _______________________________________ _____________________ Pull out lashes or eyebrows compulsively (Trichotillomania) ____________________ Eyebrow Tinting, date of last service: _______________________________ ____________________ Eyelash Tinting, date of last service: _______________________________ ____________________ Other eye disorders: ____________________________________________ LIPS: Check all the following that apply. _______________________ Chapped lips _______________________ Cold Sores / fever blisters / herpes around mouth. If yes, a prescription of
Zovirax will be required prior to any lip procedure
_______________________ Collagen injections – location __________________________________ _______________________ Fat transfer injections – location ________________________________ _______________________ Gore Tex implants – location __________________________________ IS THERE ANY MEDICAL REASON WHY YOUR GENERAL PRACTITIONER WOULD OBJECT TO YOU HAVING THIS PROCEDURE COMPLETED? YES / NO
SKIN: Check all of the following that apply. _______________________ Any other tattoos – Location: __________________________________ _______________________ Age of tattoo Any problems: __________________________________ Use of sunlamp /tanning bed/suntan outdoors _______________________________ _______________________ Currently using glycolic acid or other AHA skin products YES / NO ______________________ Have you ever had a chemical peel? When?________________________ What type of peel? __________________________________________________________________ ______________________ Do you have a scar you want camouflaged? Age of scar ______________ ______________________ Any keloid or hypertrophic scars – location: ________________________ _______________________ Bruise or bleed easily _______________________ Healing problems ______________________ Other active dermatological disorders. Describe: ____________________ __________________________________________________________________________________ GENERAL MEDICAL: Check all of the following that apply _______________________ High blood pressure _______________________ Diabetes ______________________ Current on blood thinners or anticoagulants such as Aspirin, Ibuprofen, Coumadin, Alcohol _______________________ Haemophilia or other clotting disorders _______________________ Mitral valve prolapse or valve implants _______________________ Heart palpitations _______________________ Have you taken Accutane within the last 6 months? _______________________ Are you pregnant or nursing? _______________________ Ever had hepatitis – when? ___________________________________ __________________________________________________________________________________ _______________________ Autoimmune disorders Please list any surgeries: __________________________________________________________________ If you are planning cosmetic or other surgery in the near future, please describe: ______________________ ___________________________________________________________________________________ List all medications, prescription and non-prescription, that you have taken in the last two weeks: ______________________________________________________________________________________ ______________________________________________________________________________________ If you are currently under a physician’s care for any condition, please describe: _______________________ ______________________________________________________________________________________ Physician’s Name: ___________________________ City: ________________ Phone: _________________ This history has been reviewed by the technician and my questions have been satisfactorily answered. I have also received and reviewed a copy of the Pre-procedure Information sheet and After Care Sheet, understand them and agree to follow them
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