Smoky Eyeliner Confidential Medical Profile


Clients Name:   

Date:   

Date of Birth:  

Address:   

Phone:   

Allergies:   

Are you under the age of 18?

Are you pregnant or nursing?

Have you had any blood thinning agents in the last 7 days?

Have you had any mood altering agents within the last 24 hours?

Do you have a history of herpes, cold sores, or fever blisters?

Do you have a history of skin disorders or remarkable skin sensitivities?

Do you have problems with healing?

Have you had any permanent makeup procedures before?

Have you had any previous problems with tattoos/permanent makeup?

Are you currently undergoing chemotherapy or radiation?

Are you currently using Retin A or alpha-hydroxy skin care products?

Have you had a chemical laser peel in the last 30 days?

Do you wear contact lenses or false eyelashes?

Please check that applies:

 

Please list all medications you are currently taking:

Practitioner makes no attempt, or claim, to practice medicine. Some individuals will have complications related to permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. By signing this consent you are acknowledging that you are in good health and there are no apparent reasons to restrict you from receiving a tattoo.

 

Leave this empty:

Signed by Katelyn McCloy
Signed On: October 1, 2018

Beauty By Katelyn McCloy http://www.aestheticbeautybar.co
Signature Certificate
Document name: Smoky Eyeliner Confidential Medical Profile
Unique Document ID: 330d423832cff57ea323e481643964ed55ad3873
Timestamp Audit
July 10, 2018 4:48 pm EDTSmoky Eyeliner Confidential Medical Profile Uploaded by Katelyn McCloy - katelynmccloy@yahoo.com IP 69.180.24.219, 127.0.0.1