Pre-Treatment Client Consultation Form
Claire Martinez - Micro Pigmentation Practitioner
Email address *
Full Name *
Your answer
Address *
Your answer
Date Of Birth *
Your answer
Contact Number *
Your answer
Emergency Contact Name and Number *
Your answer
Desired Services
Desired Services *
Required
Have you ever had an allergic reaction to any of the following? Please tick
If you ticked an allergy box please provide a brief description of what happened.
Your answer
EYEBROWS / EYELASH ENHANCEMENTS
Please mark if you have or experience any of the following eye disorders:
Please mark if you have or experience any of the following skin disorders:
Other eye disorders:
Your answer
Eyebrow tinting, date and last service
Your answer
Eyelash tinting, date and last service:
Your answer
Other hair loss (please describe)
Your answer
LIPS
Please mark if you have or experience any of the following:
Cold sores - if yes, please list which medication you have been using prior to lip procedure:
Your answer
Collagen injections - Location of injections and date:
Your answer
Gortext implants - Location of implants and date:
Your answer
Fat transfer injections - Location of injections and date injected:
Your answer
SKIN
Please mark if you have or experience any of the following
Currently using glycolic acid or AHA products? Please specify:
Your answer
Any keloid or hypertrophic scars? Please specify where:
Your answer
GENERAL MEDICAL
Please mark if you have or experience any of the following:
Please mark if you are taking/have recently taken the following blood thinners:
Have you taken Roaccutane within the last 6 months? Details (if any):
Your answer
Are you pregnant or breast feeding? Due date/Age of baby:
Your answer
Have you ever had Hepatitis? When?
Your answer
Have you ever had seizures? Please describe:
Your answer
Do you suffer any Autoimmune Disorders? Please describe:
Your answer
Have you ever had any blood transfusions?
Your answer
Have you been tested for HIV/AIDS? Results?
Your answer
Please list any relevant surgeries you have undergone:
Your answer
IMPORTANT: Please list all medications, vitamins, treatments etc. whether prescribed or non-prescribed that you have taken in the last two weeks:
Your answer
Are you currently under any treatment by a Physician?
If you are currently under a Physician’s care for any conditions, please name your Physician and describe the care currently being received:
Your answer
Any other conditions or symptoms that Claire should be made aware of:
Your answer
Basic Tattoo Theory
MUSIC
Please list your favourite genre, artist or songs you'd like to listen to during your appointment:
Your answer
CLIENT AGREEMENT
This history has been reviewed by the practitioner and client. All questions regarding the procedure have been satisfactorily answered by the practitioner. The client has been supplied with an information kit and all relevant information relating to the procedure has been discussed and agreed too. This information will be strictly confidential. *
Required
I have read and agree with the information on the Department of Health website regarding cosmetic tattooing: https://goo.gl/rQApde *
Required
By entering your full name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Your answer
FUTURE TREATMENTS
I acknowledge that the above information is all still correct, accurate, and that I understand the implications of the treatment I am about to receive.
By entering your full name in the box below, you are effectively providing your signature, indicating that the above information is all still correct, accurate, and that I understand the implications of the treatment I am about to receive.
Your answer
A copy of your responses will be emailed to the address you provided.
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