JAKLINE STUDIO PERMANENT MAKE UP

Client Medical Health Form for Semi-Permanent Tattoo

Name and Surname

Age

Phone

Email

Have you received chemotherapy or radiation in the last 6 months?
NoYes

If you are pregnant, nursing or under 18 years of age, procedure CANNOT be performed, NO EXCEPTIONS

List (if any) medications you take for thinning the blood

Do you have any known drug or food allergies? If so, please list and explain

Do you have an allergy to any of the following?
LatexVaselineCrayonsGlycerinMetalLanolin BeeswaxHair DyesLidocaineBenzocaine

Have you ever had a cold sore, shingles or herpes simplex I or II?
NoYes

If you answered yes to the question above, please obtain an antiviral prescription from your doctor for prevention, JAKLINE STUDIO Permanent Make Up will not be liable for an outbreak of the above due to the procedure.

Are you currently under regular care of a physician for a chronic issue?
NoYes

If yes, please detail the issue

Physician's Name

Issue

Are you required to take antibiotics before going to the dentist?
NoYes

If yes, please detail why

Do you have any of the following conditions? Please select
Hair LossSensitivity to CosmeticsProlonged BleedingDiabetes IDiabetes IITrichotillomaniaArtificial Heart ValveLow Blood PressureEpilepsyHigh Blood PressureHemophiliaCirculatory ProblemsFainting Spells or DizzinessAlopeciaHypertrophic/Keloid ScarsAnemiaLiver Disease/HepatitisHIVAcneHumors, Growths, CystsCancerDermatitis/RosaceaVitiligoHealing ProblemsThyroid DisturbancesPsoriasisImmunocoprimisedBotox/Filler Injections

Do you scar easily?
NoYes

Do you bruise/bleed easily?
NoYes

Contraindications for semi-permanent procedure:

Liver disease - high risk of infection
Pregnancy/Nursing
Compromised skin near brow area (Current injury or active acne)
High blood pressure
Auto-Immune Disease
Thyroid/Grave's Disease
Cancer (At any stage including remission)
Any other medical condition that causes slow healing or a high risk of infection

I confirm that I have read and understood all the questions in this questionnaire

I confirm that I have read and understood all the post procedure homecare instructions

I confirm that I am aware that no re-touch, alteration or claim can be made to the procedure before a minimum period of four weeks from the procedure

I understand that if after 7 days irritation/redness/infections occurs, this is not related to the procedure

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