Confidential Medical Form - New Path Spa by Magda

Name:(Required)

Date Of Birth(Required)

Address:

City:

Postal Code:

Mobile Phone:

Home Phone:

To avoid unforeseen complications, please answer the following questions:

Are you over the age of 18?(Required)

Yes

Have you had any aspirin or blood thinning products within the last 7 days?(Required)

Yes

Any mood-altering drugs within the last 8 hours?(Required)

Yes

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

Yes

Are you sensitive to Latex?(Required)

Yes

Are you pregnant or nursing?(Required)

Yes

Are you required to take antibiotics during dental or invasive medical Procedures?(Required)

Yes

Have you had a chemical or laser peel? If so, when?(Required)

Yes

Date

Do you have problems healing from minor wounds?(Required)

Yes

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

Yes

Are you currently undergoing radiation or chemotherapy?(Required)

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.(Required)

Yes

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

Yes

Have you had a permanent make-up procedure before?(Required)

Yes

Do you take immunosuppressive mediation such as anti-inflammatory or steroids?(Required)

Yes

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

Yes

Is there any history of skin diseases or remarkable skin sensitivity?(Required)

Yes

Do you have eczema?(Required)

Yes

Do you have psoriasis?(Required)

Yes

Do you have hemophilia?(Required)

Yes

Do you have vitiligo?(Required)

Yes

Do you suffer from rosacea?(Required)

Yes

Do you have any allergies?(Required)

Yes

Have you had plastic surgery?(Required)

Yes

Are you contemplating plastic surgery?(Required)

Yes

Do you have high or low blood pressure?(Required)

Yes

Please select:

High

Low

Do you have asthma?(Required)

Yes

Do you wear a pacemaker?(Required)

Yes

Do you have any medical implants?(Required)

Yes

Do you have blocked tear ducts?(Required)

Yes

Do you bruise easily?(Required)

Yes

Do you have tendency to faint or become dizzy?(Required)

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.(Required)

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

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

- 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.(Required)

- 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(Required)

- 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.(Required)

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

- 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.(Required)

Client Signature:(Required)

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:

All prices are in Canadian dollars (CAD)

Confidential Medical Profile

To avoid unforeseen complications, please answer the following questions:

Services

General Stuff