THE ART OF PERMANENT COSMETICS
452 Chamberlain Street Southeast
Atlanta, GA, 30312
Atlanta Microblading. ORGANIC EYEBROW TATTOO EXPERTS
Please Review this Medical Health Form prior to scheduling your Microblading Procedure. BASED ON YOUR CURRENT HEALTH, YOU MAY NOT BE ELIGIBLE TO RECEIVE PERMANENT MAKEUP AT THIS TIME.Please be prepared to disclose all of the medications you have taken in the last 6 months Please do not take Aspirin or Ibuprofen prior to Microblading Procedure* Allergies: Please submit the form below if you have ever had an allergic reaction or concern about any of the following:Lanolin Latex Rubber Nuts Medication Metals Hair dyes Drugs Foods Lidocaine Paints Crayons Glycerine Antibiotic ointments Anesthetics Submit any other allergy concerns below* Dental injection to numb your mouth MRI scan scheduled in the next 3 months Laser or IPL scheduled in the next 3 months Do you give blood? Prior to dental procedures do you receive antibiotic therapy? Have you had Botox or other injectables? Are you currently under the care of a doctor or hospital specialist? If “Yes” please share relevant details of Doctor and condition currently being treated below:Review the list below for medical or mental condition(s) that apply to you:Abnormal Heart ConditionPalpitationsBody Dysmorphic Disorder (BDD) Mitral Valve ProlapsedHeart MurmurDepressionRheumatic FeverPacemakerArtificial Heart ValvesLow-Self EsteemAnemiaHemophiliaProlonged BleedingHigh Blood PressureLow Blood PressureCirculatory ProblemsDiabetesEpilepsyFainting Spells or DizzinessThyroid DisturbancesLiver DiseaseKidney DiseaseGlaucomaStomach UlcersTumors, Growths or CystsCancerTuberculosisStrokeHIVProsthetic Hip or JointSystemic Lupus ErythematosusHepatitis ShinglesCataractsBlurred VisionDry EyesDo you suffer from eye Infections?AlopeciaOcular HerpesWatery EyesContact LensesEyelid SurgerySeverely Chapped LipsTrichollomaniaRecent Hair LossCold Sores (Herpes simplex)Auto Immune ConditionsGore-Tex Implants/Silicone InjectionsOther TattoosFat Transfer EnhancementBruise or Bleed EasilyBotox EnhancementFrequent Use of Sun bedDermal Fillers (Example: Restylane, Juvederm)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?
Thank you for your submission! We will review your concern and respond within 2- 3 business days.