Confidential Medical Form - New Path Spa by Magda

Name:*

Date Of Birth*

Address:

City:

Postal Code:

Mobile Phone:

Home Phone:

To avoid unforeseen complications, please answer the following questions:

Are you over the age of 18?*

Yes

Have you had any aspirin or blood thinning products within the last 7 days?*

Yes

Any mood-altering drugs within the last 8 hours?*

Yes

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

Yes

Are you sensitive to Latex?*

Yes

Are you pregnant or nursing?*

Yes

Are you required to take antibiotics during dental or invasive medical Procedures?*

Yes

Have you had a chemical or laser peel? If so, when?*

Yes

Date

Do you have problems healing from minor wounds?*

Yes

Have you had any problems from tattoos or has your physician advised you not have a tattoo for any reason?*

Yes

Are you currently undergoing radiation or chemotherapy?*

Yes

Do you wear contact lenses? (If yes, I understand they must be removed during eyeliner procedures and should be replaced until the next day.*

Yes

Are you allergic to any metals? (For example, you can only wear 14K gold)*

Yes

Have you had a permanent make-up procedure before?*

Yes

Do you take immunosuppressive mediation such as anti-inflammatory or steroids?*

Yes

Are you allergic to topical antibiotic preparations or desensitizers such as Polysporin, Bacitracin, Neosporin, the “Caine” family of drugs or Petroleum?*

Yes

Is there any history of skin diseases or remarkable skin sensitivity?*

Yes

Do you have eczema?*

Yes

Do you have psoriasis?*

Yes

Do you have hemophilia?*

Yes

Do you have vitiligo?*

Yes

Do you suffer from rosacea?*

Yes

Do you have any allergies?*

Yes

Have you had plastic surgery?*

Yes

Are you contemplating plastic surgery?*

Yes

Do you have high or low blood pressure?*

Yes

Please select:

High

Low

Do you have asthma?*

Yes

Do you wear a pacemaker?*

Yes

Do you have any medical implants?*

Yes

Do you have blocked tear ducts?*

Yes

Do you bruise easily?*

Yes

Do you have tendency to faint or become dizzy?*

Yes

Date

Name

First Last

Date Of Birth:

Proof of age of Client and Type of ID:

The nature and method of the proposed Permanent Make-up (tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand there may be a certain amount of discomfort associated with the procedure. Fading or loss of pigment may occur. I agree as follows: (Please read and initial the following statements.)

- I acknowledge that it is not possible to determine whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such a reaction is possible. I have information the practitioner of any existing problems.*

- I acknowledge that complications are always possible as a result of the permanent make-up procedure, particularly if post-procedural instructions are not followed.*

- I realize that my body is unique, and the practitioner cannot predict how my skin may react as a result of the procedure.*

- I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the result.*

- I understand that future laser treatments or other skin altering procedures, such as plastic surgery, implants, and /or injections may alter or degrade my permanent make-up and that such changes are not the fault of the practitioner. I further understand that such changes in my appearance may not be correctable through further Permanent Make-up procedures*

- I confirm that aftercare instructions have been explained to me and that a written aftercare advice sheet has been given to me. I agree that it is my responsibility to read this and follow the instructions, until the site has healed.*

- I understand that a patch test of pigment is required for clients who have not had any permanent makeup or tattoos before.*

- I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedures (18 years) and that I am not currently under the influence of alcohol or drugs.*

Client Signature:*

Date

Witness/Practitioner Signature:

I hereby request and consent to the application of permanent colour and consent to have the following procedures performed by:

Please select any of the following procedures that pertain to you:

Eyeliner

Eyebrows

Lipliner

Full Lip Colour

Scar Camouflage

Beauty Mark

Areola Repigmentation

Other

If other, please specify:

Confidential Medical Profile

Confidential Medical Profile

To avoid unforeseen complications, please answer the following questions: