Medical Profile Form

Even though you ask most of the medical questions over the phone, this form gets much through.

• Once your client fills this document, take your time reading this form.
• If anything jumps out, ask your client to explain more.
• If you do not feel comfortable with any answers in this form, do not do microblading on the client.

To Avoid Unforeseen Complications, Please Answer The Following Questions

Are you under 18? ___ YES ___ NO If so, guardian’s initials_________________

Are you allergic to any metal? ___ YES ___ NO

Have you had any aspirin or blood thinners in the past week? ___ YES ___ NO

Have you ever had any semi-permanent makeup procedures before? ___ YES ___ NO

Any mood altering drugs within the last 8 hours? ___ YES ___ NO

Are you on any immunosuppressive medications such anti-inflammatories or steroids? ___ YES ___ NO

Do you have a history of cold sores, herpes, or fever blisters? ___ YES ___ NO

Are you allergic to topical antibiotic preparations or desensitizers? ___ YES ___ NO

Are you sensitive/allergic to latex? ___ YES ___ NO

Is there any history of skin diseases or remarkable skin sensitivities? ___ YES ___ NO

Have you had a chemical peel or laser? ___ YES ___ NO If so, when?_____________________________

Are you currently taking any vitamins a or e in any form? ___ YES ___ NO

Do you have problems healing? ___ YES ___ NO

Are you pregnant or nursing? ___ YES ___ NO

Are you currently undergoing radiation or chemotherapy? ___ YES ___ NO

Are you required to take antibiotics during dental or invasive medical procedures? ___ YES ___ NO

Are you currently using any retin-a or alpha-hydroxy skin care products? ___ YES ___ NO

Do you wear contact lenses? (if yes i understand they must be removed during my eyeliner procedure and should not be replaced until the next day) ___ YES ___ NO

Previous problems with tattoos or has your physician advised you not to have a tattoo at this time?

___ YES ___ NO

List all medications you are currently taking: _____________________________________________________________________________________

_____________________________________________________________________________________

Please Circle Any Of The Following Which May Pertain To You

Heart Conditions

Allergies To Makeup

Accutane Treatment

Dry Eyes

Diabetes

Stroke

Chest Pains

Alopecia

Refractive Eye Surgery

Glaucoma

Trichotillomania

Keloid/Hypertrophy Of Scars

Epilepsy/Seizures

Shortness Of Breath

Autoimmune Disorder

Cancer (Any)

Hepatitis/ Jaundice

HIV

Tendency To Develop Fever

Kidney Disease

Blisters On The Lip

Ocular Herpes

Hyperpigmentation

Hypopigmentation

Tendency To Bleed Excessively From Minor Injuries

List any other medical conditions or issues not addressed above: _____________________________________________________________________________________

_____________________________________________________________________________________

Primary Physician’s Name:__________________________________________________

Primary Physician’s Phone Number:____________________

By signing below, I acknowledge, understand and agree that:

The staff at Z Beauty Spa does not practice medicine, does not accept health insurance, and have made no representation to the contrary;

The information provided on this form is accurate and complete to the best of my knowledge, and that Z Beauty Spa / Salons by JC is not responsible for complications or problems arising from any incorrect or omitted information;

Some individuals will have complications related to semi-permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold Z Beauty Spa and its employees and contractors harmless for same;

The staff at Z Beauty Spa will use the information provided above to assess my suitability for the proposed micropigmentation services.

Parent/ Legal Guardian (If Under 18) Signature: _____________________  Date: ___________________

Practitioner statement:

I have personally reviewed the above information with my client or the client’s representative.

Practitioner Signature: ___________________________________       Date: ___________________