Laserfiche WebLink
t <br /> r- <br /> -= CLIENT CONSULTATIONMEDICAL <br /> rf-VERLflSTING HEALTH FORM FOR MICROBLADING/PMU <br /> Mame: sumame: DOB: Age: <br /> Address: Post Code <br /> Contact Pio: Email: Occupation: <br /> gist any medications you have been taking in the past 6 months: <br /> Have you received`chemotherapy or radiation in the past year?. <br /> Have you ever had an allergic reaction to one of the following?Lanolin F-1Latexrubber Yaselir ,Medication <br /> Metals O Hair Q Dyes' a Foods ❑ Lidocaine [—] Paints ❑Crayons Glycerine <br /> ail <br /> Ham <br /> youEverhadomofthe iW.RetainAr in,"2auee{cs ar rtsa. Prolonged bleeding❑ <br /> Trichotikxnania E]Low Bloat Pressure n Artificial Heart vahres Diabetes I HaemophiliaaF] Fainting spells or dizziness <br /> High blood pressure ❑ Liver disease ❑circulatory Problems [—�EpilepsyEl Tumours growths or cysts F]Herpes El <br /> Thyroid disturbances ;F--]HlV' D Hair k.❑Hepatitis Cancer F-1 Chemical m laser peel within 6 weeks'❑ Alopecia <br /> AHA preparations in the last 2 weeks ❑;Fat injections,Botox injections,Collagen injections El Hypertrophic scars F Keloid Scars <br /> Healing problems ❑ to you scareasily?, qoy bruise or bleed ? Areyou aarrently Pregnant or nursing? <br /> What are the main concerns relating area to be treated? <br /> What wouldyou like toimprove? <br /> FOR THERAPIST USE: <br /> Note pigments,blades,techniques to be used for this client <br /> Please read the following statements carefully. Microbtading/PMU is a way of cosmetic tattooing. <br /> Re-touch procedures may be required. A heaft"period Of 4 weeks is required before a touch up <br /> procedure can be performed.On a rare occasion:the pignf may migrate;under the skin:Procedure of <br /> microblading/PMU may be slightly uncomfortable. The pigments will fade. Immediately after the <br /> procedure,the pigment can appear 30-509 darker than the desired result Although extremely rare,there <br /> might be an immediate or <br /> delayed allergic reaction to pigment A negative patch test result does not guarantee that you will not <br /> develop an allergic reaction afterthe full procedure.Allergic reactions to anaesthetic can occur.Permanent <br /> cosmetics cannot be applied to pregnant women or nursing mothers.Permanent cosmetics cannot be <br /> applied to any person under the age of 18.Infections can occur if aftercare instructions are not followed <br /> correctly. There may be swelling and redness following the procedure. You may experience minor <br /> bleeding.if you have an MRI scan within 3 months after microblading procedure,you should notify/discuss <br /> 1 have received an after care leaflet and I'm fully aware of the after care procedures. <br /> have fully understood the Information provided above. <br /> 1 can confirm that all of the information provided by me,ts correct and truthful. <br /> Clients Full Name: Clients signature: Date: <br /> Technician's Full Name Clients signature: Date: <br /> Please continue to general'consent and procedure permit form on reverse <br /> Everlasting Brans Client Consultation Form 2017 <br />