Medical History Form Please complete the medical history form below and submit it prior to your Microblading appointment. Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Emergency Contact Person * First Name Last Name Phone (###) ### #### Do you presently have or previously had any of the following? Please check the box of all that apply. Do you presently have or previously had any of the following. Please check the box of all that apply. History of MRSA Botox Diabetes Cold Sores / Fever Blisters, etc Hepatitis (A, B, C, D) Forehead / Brow Lift Easy Bleeding Face Lift Alcoholism Abnormal Heart Condition Take Meds Before Dental Work Chemical Peel Currently Pregnant / Breastfeeding Brow or Lash Tinting Autoimmune Disorder Oily Skin Cancer Accutane or Acne Treatment Chemotherapy / Radiation Tan by Booth or Sun Difficulty Numbing with Dental Work Taking Blood Thinners (Aspirin, Ibuprofen, Alcohol, Coumadin, etc) Allergic Reaction to Any Medications Such As: Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carpool, Lecithin, Propylene Glycol, Vitamin E, Acetate, etc. Allergies to Metals, Foods, etc. Do you use skincare productions containing Retin-A, Glycolic Acid or Alpha Hydroxyl? Any diseases or disorders not listed? If you checked yes to having a chemical peel above, please provide the date of your last treatment: If you checked yes to having cancer, please provide the year: Please specify any allergies. (Foods, metals, etc) Please list any medications or vitamins you are presently taking: By typing my name and today's date in the box below, I agree that all of the above information is true and accurate to the best of my knowledge. Thank you!
