Medical Consent Form
Consent Form for Medical Procedures: Cosmetic Art by Micah
By signing below, I acknowledge, understand and agree that:
• the information provided on this form is accurate and complete to the best of my knowledge, and that Micah is not responsible for complications or problems arising from any incorrect or omitted information;
• some individuals will have complications related to semi-permanent makeup application. These
complications are usually mild and last only a few days. However, extreme complications are always a
possibility. I accept these risks and agree to that I understand the risks.
• Micah Mellalieu will use the information provided above to assess my suitability for the proposed micropigmentation services.
Email address *
Name *
Your answer
Email *
Your answer
Address *
Your answer
Phone number
Your answer
Please outline the procedure you have selected, including what pigments etc you have chosen
Your answer
Are you pregnant, nursing or attempting to become pregnant?
Do you have any of the following medical conditions?Heart Conditions/ Allergies To Makeup Accutane Treatment/ Dry Eyes /Diabetes /Stroke /Chest Pains Alopecia/ Refractive Eye Surgery/Glaucoma/Trichotillomania/Keloid/Hypertrophy Of Scars Epilepsy/Seizures/ Shortness Of Breath/Autoimmune Disorder/ Cancer (Any)/Hepatitis/ Jaundice/ Hiv/ Kidney Disease/ Tendency To Develop Fever/Blisters On The Lip Ocular/ Herpes/Hyperpigmentation/ Hypopigmentation/Tendency To Bleed Excessively From /Minor Injuries
Please indicate which medications you are currently on:
Your answer
Do you have any allergies to any of the following: metals, latex, makeup, antibiotics, medications, alcohol swabs, medical dressings, chemical sensitivities?
If you answered yes to the above question, please indicate which you are allergic to:
Your answer
Have you had a chemical peel or laser?
Are you currently taking any herbs or supplements, including vitamins?
Your answer
Do you have problems healing or bruise easily?
Do you have to take antibiotics during surgery or medical procedures?
Are you currently using any retin-a or alpha-hydroxy skin care products?
Do you wear contact lenses (should be removed and not placed back for 24 hours after procedure).
Any previous problems with tattoos, or been advised by your doctor to not get a tattoo during this time?
Are you currently undergoing chemotherapy, dialysis, or radiation?
Have you had any mood altering drugs in the last 24 hours?
Have you had any alcohol in the last 24 hours?
Date of Birth
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DD
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YYYY
Date of Consent for Procedure
MM
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DD
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YYYY
By placing your name here you are indicating that you consent to this procedure.
Your answer
A copy of your responses will be emailed to the address you provided.
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