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Medical Questionnaire
Client Personal
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Full Name: *
Date of birth: *
MM
/
DD
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YYYY
Email: *
Address: *
Phone number: *
Emergency Contact: ( Full name/Relation/Contact number). *
Reason for treatment  (Density, Hairline restoration, scar camouflage etc.) 
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How is your general health? 

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Do you suffer from any medical/other conditions which may affect pigment implantation? 

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If yes, please specify/If no, write N/A

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Do you suffer from any allergies (i.e. latex, medications, etc.) 
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If yes, please specify/If no, write N/A
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Are you using Blood Thinners, Aspirin, Steroids, Accutane? 

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If yes, please specify/If no, write N/A
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Do you suffer from Alopecia (Areata, Totalis, Universalis etc) 

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and if so, has the type been diagnosed and cleared for treatment by your doctor?

Please specify

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Have you had alcohol, drugs and/or the above in the last 24 hours ? 

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If so, how many units? 
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How does your skin scar? 

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Have you ever been declined cosmetic treatment, pigment implantation, or had a hair transplant treatment reject? 

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If yes, please specify/If no, write N/A
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COVID 19

 Have you traveled overseas, to an interstate red zone, experienced any flu like symptoms or been exposed to anyone who tested positive for Covid 19 within the last 2 weeks?

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Please list any additional comments or questions you many have 

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I have read the above and answered in a true manner and I am aware that Triple 8 Ink reserve the right not to treat patients on the information given, or on the belief that the information is not correct, thus giving Triple 8 Ink the right to refusal in the best of interest of all parties concerned. 

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