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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.
THE CLIENT ALSO EXPLICITY ACKNOWLEDGES THAT MICAH MELLALIEU IS NOT RESPONSIBLE FOR ANY RELATED COMPLICATIONS RELATED TO PREVIOUS PROCEDURES INCLUDING UNDERLYING PROBLEMS OR MALFORMATIONS IN THE AREA OF PROCEDURE, WHERE IT HAS BEEN EXPLAINED THAT CARRYING OUT THE PROCEDURE WOULD COME WITH AN OVERALL RISK OF COMPLICATION. PARTICULARLY WHERE THE CLIENT HAS BEEN ADVISED TO SEEK SPECIALIST ADVICE TO CORRECT THE AREA OF APPLICATION.
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* Indicates required question
Email
*
Your email
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?
Yes
No
Clear selection
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
Yes
No
Please indicate which medical conditions are relevant:
Other:
Clear selection
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?
Yes
No
Other:
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?
Yes
No
Clear selection
Are you currently taking any herbs or supplements, including vitamins?
Your answer
Do you have problems healing or bruise easily?
Yes
No
Clear selection
Do you have to take antibiotics during surgery or medical procedures?
Yes
No
Maybe
Clear selection
Are you currently using any retin-a or alpha-hydroxy skin care products?
Yes
No
Unsure
Clear selection
Do you wear contact lenses (should be removed and not placed back for 24 hours after procedure).
Yes
No
Clear selection
Any previous problems with tattoos, or been advised by your doctor to not get a tattoo during this time?
Yes
No
Other:
Clear selection
Are you currently undergoing chemotherapy, dialysis, or radiation?
Yes
No
Maybe
Clear selection
Have you had any mood altering drugs in the last 24 hours?
Yes
No
Maybe
Clear selection
Have you had any alcohol in the last 24 hours?
Yes
No
Maybe
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Date of Consent for Procedure
MM
/
DD
/
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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