Laserfiche WebLink
MICROBLADING <br /> ��. CLIENT INFORMATION AND HISTORY <br /> (Continued) <br /> NAME DATE <br /> Olease be as Eccurate as possible when filling in the following information <br /> CLIENT MEDICAL HISTORY <br /> Y/ N I Y/ N <br /> O O History of MRSA O o Currently Pregnant or Breastfeeding <br /> O O Botox O O Brow/ Lash Tinting <br /> O O Diabetes o 0 Autoimmune Disorder <br /> i <br /> 0 0 Hepatitis A, B, C, or D 0 0 Oily Skin <br /> O O Forehead/ Brow Lift i O o Cancer(If yes, what year? ) <br /> o o Easily Bleed O O Accutane or Acne Treatment <br /> 0 o Facelift 0 O Chemotherapy/ Radiation Therapy <br /> o o Alcoholism O O Abnormal Heart Condition <br /> o o Abnormal Heart Condition o O Tan by Booth, Salon, or Sun <br /> O o Take medication before Dental Work o o Tumors/ Growth/Cysts <br /> i <br /> O o Chen-;ica Peel o O Difficulty Numbing with Denta Work <br /> o O Any diseases or disorders not listed o o Allergic to any medications <br /> If yes, list: If yes, list: <br /> 0 o Allergic to any metals,food, etc. o o Taking any medications or vitamins <br /> If yes, list: If yes, list: <br /> 0 o Taki-g Blood Thinners(e.g.Aspirin, O o Use skin products containing Retin <br /> Ibup-ofen, etc.) A, Glycolic Acid, or Alpha Hydroxyl? <br /> If yes, list: <br /> I agree that all the above information is true and accurate to the best of my knowledge. <br /> Signed: <br /> Copyright CALashBoutique <br />