Micoblading Medical Form | Missy Beautique

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Microblading Medical Form

First Name

Surname

Email address

Phone

List any medications you've taken in the last 6 months

Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol? *

Yes

Have you received chemotherapy or radiation treatment in the last year If you answered yes to the above, please provide your Doctors name and surgery address *

Yes

Tick if you have you ever had an allergic reaction to any of the following:

Lanolin

Crayons

Plants

Nuts

Medication

Hair dyes

Drugs

Lidocaine

Paints

Antibiotics or ointments

Latex Rubber

Anaesthetics [please note below]

Metals

Other [please note below]

Foods

Additional information

Have you ever had any Dental injections to numb your mouth? *

Yes

Are you presently pregnant or breast feeding? (We can’t do treatment for pregnant or breastfeeding women) *

Yes

Do you have MRI scan scheduled in the next 3 months? *

Yes

Do you have Laser or IPL scheduled in the next 3 months? *

Yes

Do you give blood? *

Yes

Are you currently under the care of a doctor or hospital specialist? (If yes you will need GP referral) *

Yes

Tick if you have any of the following:

Abnormal Heart Condition

Keloid scars

Mitral Valve Prolapsed

Accutane within 6 months

Rheumatic Fever

Palpitations

Artificial Heart Valves

Pacemaker

High Blood Pressure

Anaemia

Circulatory Problems

Low Blood Pressure

Epilepsy

Diabetes

Thyroid Disturbances

Auto immune system conditions

Kidney Disease

Fainting or dizziness

Stomach Ulcers

Liver Disease

Cancer

Glaucoma

Stroke

Tumours, Growths or Cysts

Prosthetic Hip or Joint

Tuberculosis

Alopecia

HIV

Trichilemmoma

Systemic Lupus Erythematosus

Shingles (within the last 4 months)

Other

Recent hair loss

Steroids within six months

Additional information

Do you have healing problems *

Yes

Do you scar in a raised manner *

Yes

Do your scars heal darker colour than the rest of your skin *

Yes

Have you had chemical or laser peel within 6 months *

Yes

Have you had Retin A within 6 months *

Yes

Your Signature

Select a date * required

Thanks for submitting!

Thursday 9am - 7:30pm

Friday 9am - 5:30pm

Saturday 9am - 4pm

Monday CLOSED

Tuesday 9am - 5:30pm

Wednesday 9am - 5:30pm

Terms and Conditions

Consent Form

Medical Form

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