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Beautiful Beastie Medical Form

First and last name: * Please enter your name.

Date of birth: *

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Email: * Please enter your email.

Phone number: * Please enter your phone number.

Gender: * Please select one here.

Please fill in Address: *

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To avoid unforeseen complications, please answer the following questions:

Are you under 18? *

yes

no

Please select at least one choice above.

Have you ever had any semi-permanent makeup procedures before? *

yes

no

Please select at least one choice above.

Are you allergic to metal? *

yes

no

Please select at least one choice above.

Have you had any aspirin or blood thinners in the past week? *

yes

no

Please select at least one choice above.

Have you ever had any semi-permanent makeup procedures before? *

yes

no

Please select at least one choice above.

Any mood altering drugs within the last 8 hours? *

yes

no

Please select at least one choice above.

Are you on any immunosuppressive medications such as anti-inflammatories or steroids? *

yes

no

Please select at least one choice above.

Do you have a history of cold sores, herpes, or fever blisters? *

yes

no

Please select at least one choice above.

Are you allergic to topical antibiotic preparations or desensitizers? *

yes

no

Please select at least one choice above.

Are you sensitive/allergic to latex or nitrile? *

yes

no

Please select at least one choice above.

Is there any history of skin diseases or remarkable skin sensitivities? *

yes

no

Please select at least one choice above.

Have you had a chemical peel or laser? If so, when? * Please enter your answer here.

Are you currently taking any vitamins a or e in any form? *

yes

no

Please select at least one choice above.

Do you have any problems healing? *

yes

no

Please select at least one choice above.

Are you pregnant or nursing? *

yes

no

Please select at least one choice above.

Are you currently undergoing radiation or chemotherapy? *

yes

no

Please select at least one choice above.

Are you required to take antibiotics during dental or invasive medical procedures? *

yes

no

Please select at least one choice above.

Are you currently using renting-a or alpha-hydroxy skin care products? *

yes

no

Please select at least one choice above.

Do you wear contacts? If yes, I understand they must be removed during my eyeliner procedure and should not be replaced until the next day. *

yes

no

Please select at least one choice above.

Previous problems with tattoos or has your physician advised you not to have a tattoo at this time? *

yea

no

Please select at least one choice above.

List all medications you are currently taking * Please enter your answer here.

Your signature *

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Signature Date *

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