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*)?
Have you received chemotherapy or radiation treatment in the last year? Yes/No
Name of Doctor:
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
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
Body Dysmorphic Disorder (BDD)
Mitral Valve Prolapsed
Artificial Heart Valves
High Blood Pressure
Low Blood Pressure
Fainting Spells or Dizziness
Tumors, Growths or Cysts
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Do you suffer from eye Infections?
Severely Chapped Lips
Recent Hair Loss
Cold Sores (Herpes simplex)
Auto Immune Conditions
Gore-Tex Implants/Silicone Injections
Fat Transfer Enhancement
Bruise or Bleed Easily
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.