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Medical History Form
The information contained in this form is confidential and only for the intended recipient, Rosebuds Salon and Spa, Trafalgar.
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Name
*
Your answer
Date of birth
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MM
/
DD
/
YYYY
Address
*
Your answer
Mobile Number
*
Your answer
E-mail
*
Your answer
How did you hear about us?
Your answer
Allergies (if you do not have any type NONE)
*
Your answer
Please list medications you take on a daily basis (including prescription and over the counter). If you do not take any type NONE.
*
Your answer
Are you 18 years of age or older?
*
Yes
No
Are you currently pregnant or breastfeeding?
*
Yes
No
Have you had permanent makeup in the brow OR lip area in the past? (If you have, please contact Rachel ASAP at 317-750-8733 or plumebrowstudio@gmail.com)
*
Yes
No
Please check if you have had any of the following:
*
Botox in the last 4 weeks
Accutane in the last year
Laser resurfacing (any type of laser treatment to the face) in the last 3 months
Sunburn in the last 30 days
AHA , Retinoids, or Vitamin A in the last 6 weeks
Chemical peel in the last 6 weeks
Microdermabrasion in the last 30 days
Brow waxing, tinting, or lamination in the last week
Injectable fillers in the brow and/or lip area in the last 6 months
NONE
Required
Do you have or have had any of the following:
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Active wounds or infections in the brow area
Autoimmune disorder
Bleeding disorder/Hemophilia
Cancer
Cold sores in the brow and/or lip area
Dermatitis, Eczema, or Psoriasis
Diabetes
Heart condition/Pacemaker/Artificial heart valve
Hepatitis or Liver disease
High blood pressure
HIV
Hormone imbalance
Hyperpigmentation/Melasma in the brow area
Latex allergy
Problems with healing
Prone to keloids or scarring in the brow area
Thyroid disease
NONE
Other:
Required
Are you currently under the care of a physician? (If so, please describe)
Your answer
By typing my name below, I acknowledge that all the information above is true and has been answered to the best of my knowledge.
*
Your answer
Today's date
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MM
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DD
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YYYY
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