DIE GORGEOUS

THE ART OF PERMANENT COSMETICS

Microblading Training Atlanta. Brow Tattoo Procedures and Permanent Makeup. Licensed Tattoo Establishment, Member of the Society of Permanent Cosmetic Professionals. Founded by Celebrity Makeup Artist, Adora Tokyo.

Please Review this Medical Health Form prior to scheduling your Microblading Procedure. YOU MAY NOT BE ELIGIBLE TO RECEIVE THIS SERVICE.

You do not need to print this information.

Permanent Makeup Procedures are not recommend for individuals with the following conditions: Pregnant or nursing, Diabetic, Undergoing Chemotherapy (Consult your doctor), Viral infections and/or diseases, Epilepsy, A Pacemaker or major heart problems, Have had an Organ transplant, Skin irritations or Psoriasis near the treated area (rashes, sunburn, acne, etc.) Anyone Prone to Keloids, or currently Sick (cold, flu, etc.), or if you have used Accutane in the past year.

Please be prepared to disclose all of the medications you have taken in the last 6 months

 Please review the questions below and plan to provide up-to date responses for your Permanent Makeup Technician. Based on your responses you may not be eligible to receive a Microblading procedure.

Have you taken any of the following in the last 2 days (Prior to Microblading Procedure*)?
Aspirin, Ibuprofen,
Yes/No   
Have you received chemotherapy or radiation treatment in the last year?    Yes/No                    
Name of Doctor:
Surgery:                                                                                                                        
Allergies: Have you ever had an allergic reaction to any of the following:
Lanolin     Latex Rubber   Nuts        
Medication    Metals    Hair dyes        
Drugs    Foods     Lidocaine        
Paints      Crayons    Glycerine        
Antibiotic ointments   Anesthetics                                                                                                     

Other allergies:                                                                                 

Have you had a dental injection to numb your mouth?   Yes/No   

Are you presently pregnant or breast feeding?   Yes/No                                      
MRI scan scheduled in the next 3 months?  Yes/No    

Laser or IPL scheduled in the next 3 months? Yes/No                                                                                                        

Do you give blood?   Yes/No                                                                                                           

Prior to dental procedures do you receive antibiotic therapy?  Yes/No                                        

Have you had Botox or other injectables?  Yes/No

Are you currently under the care of a doctor or hospital specialist?   Yes/No

If "Yes" please list relevant details of Doctor and condition currently being treated:

 
Please review the following and check any medical or mental condition(s) that apply to you:
Abnormal Heart Condition
Palpitations
Body Dysmorphic Disorder (BDD)
Mitral Valve Prolapsed
Heart Murmur
Depression
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Low-Self Esteem
Anemia
Hemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumors, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections?
Alopecia
Ocular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Severely Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (Herpes simplex)
Auto Immune Conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Transfer Enhancement
Bruise or Bleed Easily
Botox Enhancement
Frequent Use of Sun bed
Dermal Fillers (Example: Restylane)
Date of last Eyelash/Eyebrow tint:
Do you have problems healing from a wound?
Have you had a Chemical or Laser Peel procedure within the last 6 months?
Do you scar in a raised manner?
Have you been prescribed Retin-A within the last 6 months?
Do your scars heal a darker color than the rest of your skin?
Have you had any AHA preparations within the last 2 weeks?
Do you experience Keloid Scars?
Do have a sensitivity to color or skincare cosmetics?
Have you used Accutane within the last 6 months?
Do you tan regularly (Sunlight)?
Have you used steroids within the last 6 months?
Please list any other medical condition you experience that is not listed above:

Have you had a Micropigmentation procedure before?  Yes/ No
I give my consent for Micropigmentation work to be provided – which is undertaken at my request and in full understanding of all the points listed and understood.

Your health and safety is our priority. If you have questions or concerns about your Medical Health responses please complete the form below to submit an email

Name *
Name
Your medical confidentiality is important to us. Die Gorgeous Beauty Corporation respects your privacy and will not share any information contained in this email without your written consent.