Client’s First Name: _____________________ Last Name: _________________________
Date of Birth: ___ / ___ / ______ Phone: ___________________________
Email: ____________________________________
Address: ____________________________________________________________________
Surgery Address: _____________________________________________________________
I am over 18: Yes / No
I understand I will not take the following two days prior to treatment (please tick to agree):
- Anti-inflammatory e.g. ibuprofen.
- Alcohol.
- Aspirin.
- Antibuse.
Please tick if you have ever had allergic reaction to the following:
- Metals.
- Foods.
- Pigments.
- Lidocaine – if yes, no numbing can be used.
- Glycerine – if yes, you are contraindicated.
- Antiseptics.
If you ticked one or more of the above allergies, please give further details here:
Do you have any local anaesthetic allergies? If so, which ones?
Do you have any other allergies? If so, please list them:
Have you had a dental injection to numb your gums? Yes / No
Prior to dental procedures, do you receive antibiotic medication? If yes, you will require antibiotics for a lip treatment. Yes / No
Do you have difficulty with breathing or rapid heartbeat with a dental injection? Yes / No
Have you had chemotherapy or radiotherapy in the last year? Yes / No
Are you currently pregnant? If yes, you are contraindicated. Yes / No
Have you given birth since your last appointment (if you’ve had a previous treatment with us)? If yes, you will require another patch test. Yes / No
Are you presently breastfeeding? If yes, you are contraindicated. Yes / No
Do you have an MRI scan for the head scheduled in the next 6 weeks? Yes / No
Do you have laser or IPL on the face scheduled in the next 6 weeks? Yes / No
Do you give blood? Yes / No
Do you have sensitised reactions to other tattoos or permanent makeup? Yes / No
Please tick if you have any of the following conditions:
- Rheumatic fever.
- Haemophilia.
- High blood pressure that is controlled with medication. If you have a high blood pressure present that isn’t controlled by medication, your doctor’s consent is needed.
- Low blood pressure present.
- Scleroderma diagnosed.
- Stomach ulcers present.
- Cataract present (for eyeliner treatments only).
- Dry eyes (for eyeliner treatments only).
- Contact lenses (for eyeliner treatments only).
- Trichollomania.
- Skin heals dark with minor injury. If yes, you cannot have a lip treatment.
- Cosmetic allergies.
- Pacemaker.
- Asthma.
- Watery eyes.
- Alopecia.
- Recent hair loss.
Please tick if you have received any of the following treatments: If yes, your appointment will have to be postponed.
- Eyelash or eyebrow tinting in the last month.
- Use sun beds or tan regularly.
- Had laser/IPL close to site in the last 3 months.
- Had a chemical peel in the last 6 months.
- Had dermabrasion close to site in the last 6 months.
- Had cortisone within the last 6 months.
- Have a condition presently under supervision of a doctor or dermatologist.
- Have a scar on the treatment site.
Please list any medication taken in the last 6 months and state what condition each of them is treating.
If you have any of the below, you need to contact us immediately as you have a contraindicated condition. As per our terms and conditions, failure to follow all written instructions, complete all necessary medical forms and documentation prior to your allocated appointment, may prevent Faye or Laura from carrying out the treatment on the day. This will result in postponing the treatment and you will be charged 75% of the full procedure price.
- Epilepsy in the last 3 years.
- Seizures in the last 3 years.
- Vitiligo that has moved in the last year.
- Impetigo present in the treatment area.
- Spray tan present.
- Sunburn present.
- Dermal fillers in the treatment area in the last 2 weeks.
- Keloid scar with minor injury.
- Accutane within the last 6 months.
- Haemangioma in the treatment area.
- Inflammatory skin condition in the treatment area.
- Undiagnosed lumps or pains in the treatment area.
- Cuts or abrasions in the treatment area.
- Insulin dependent diabetes.
- Systemic lupus erythematosus.
- Shingles in the treatment area, previously or currently.
- Tuberculosis present.
- Glaucoma (for eyeliner treatments only).
- Ocular Herpes (for eyeliner treatments only).
- Contagious disease present.
- Fever present.
- Botox in the treatment area in the last 2 weeks.
- Retin A in the last 4 weeks.
- Chapped lips (for lip treatments only).
- Moles in the treatment area.
- Vomiting/diarrhoea present.
- AHA skin preparation in the last 2 weeks.
Your doctor’s consent will be needed if you have any of the below. The form can be found here.
- Heart condition.
- Kidney disease.
- Leukaemia.
- Cancer, chemo or radiation within the last year.
- Hepatitis present.
- Autoimmune condition (exceptions for alopecia/thyriodism).
- Nervous/psychotic conditions.
- Refractive eye surgery in the last 12 months.
- Bruise easily with minor injury.
- Scars heal easily or raised with minor injury.
- Steroids within 6 months.
- Anaemia present.
- Blood thinners or anti-coagulants.
- Heart murmur (you cannot have epinephrine, check numbing ingredients).
- Liver disease.
- Stroke.
- Tumours, growths or cysts in the last year.
- HIV.
- Eye infections regular or present.
- Bleed easily with minor injury.
If you have ticked any of the medical conditions above or you have a medical condition that is not listed, please give a brief description of how your condition affects you:
Please tick below if you have ever had a cold sore. If you have, medication is needed before your treatment can proceed.
Cold Sores – This is a herpes simplex virus that lies dormant within your system. If you have EVER suffered with a cold sore in the past you will be required to take oral medication 3 days prior to your appointment and 4 days after. This includes your finetune treatment and any future colourboost appointments on your lips).
I confirm that the information I have given is correct to the best of my knowledge.
Clients Signature: __________________________ Date: ___ / ___ / ______