Booking Health Form

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Medical History

Do you currently have or have ever had any problems with the following? For those where you have ticked 'yes', please explain in the test box below, and for surgeries/treatments, please provide date of last surgery/treatment.

Keloid or hypertrophic scars?
Hyperpigmentation?
Skin Disorder(s)?
Cold sores or shingles?
Bleeding Disorder?
Radiation Treatments?
Chemotherapy?
Wear Contact Lenses?
Cataract Surgery?
Glaucoma?
Neurological Disorder?
Diabetes?
Heart Disease?
Lung Disease?
Hepatitis or other liver disease?
Rheumatologic Disorder?
HIV/AIDS?
Are you currently pregnant?
Post-menopausal?

Please provide details and date of last treatment for all of the above that apply

Cosmetic History

Have you had or are you planning any of the following treatments? For those where you have ticked 'yes', please explain in the text box below.

Skin Laser Treatments?
Chemical Skin Peels?
Botox Injections?
Dermal Fillers?
Brow or Face Lift?
Accutane?

Please provide details and date of last treatment for all of the above that apply

Are you currently taking any blood thinners, aspirin, anti-inflammatories or other anti-platelet medication?
Do you wish to donate blood within one year of a micropigmentation procedure?
Are you planning an MRI in the near future?

Other medical conditions:

Please list any medications you are currently taking:

Are you allergic to any medications and/or products?

Attachments:

Attach images of the relevant area in gif/png/jpg/jpeg format( size limit for each file: 15MB). (Note that this is a secure website and your photos will be treated with the strictest confidence, but we need at least one photograph in order to proceed.)

File 1:

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File 2:

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File 3:

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Disclosure

Have you discussed the issue(s) surrounding the aspect(s) of your apperance that concern you with a physician, therapist or psychologist?
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