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Microblading Pre-Consult
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* Indicates required question
Name (First and Last)
*
Your answer
Current Medications:
*
Your answer
Allergies
*
Your answer
Have you ever had an allergic reaction to any of the following?
*
Lanolin
Vaseline
Metals
Dyes
Lidocaine
Crayons
Paints
Glycerine
Latex Rubber
None of the above
Other:
Required
Have you had any of the following?
*
Retain A/Retinol within the last 2 weeks
Hemophilia, Fainting Spells or Dizziness
Thyroid Disturbances
Fat/Botox/Collagen Injections in the last 6 weeks
Anemia
High blood pressure or low blood pressure
HIV
Hypertrophic scars
Keloid scars
Sensitivity to cosmetics
Liver disease
Hair loss
Prolonged bleeding
Circulatory problems
Hepatitis
Healing problems
Trichotilomania
Epilepsy
Chemical/laser peels in the last 6 weeks
Do you scar easily
Alopecia
Herpes
Diabetes
Cancer with chemo or radiation treatments
Artificial heart valve
Bruise easily
Tumors/growths/cysts
AHA Preparation‘s in the last 2 weeks
Pregnant or breast-feeding
None of the above
Other:
Required
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