Medical History Disclosure

    Client Name:

    Email:

    Phone:
     

    Please indicate any of the following health conditions that apply to you by checking the appropriate boxes below:

    Skin Conditions Specify:

    Blood Thinners Specify:

    Antibiotic Allergies Specify:

    Herpes (If yes, is there a history of herpes at the intended procedure site?

     
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    Dietary and Medication Considerations:

    What time did you consume food or drink?

    List any allergies to metals, soaps, cosmetics, alcohol, etc.:

    Are you currently taking any medications that may affect the healing process?

    If yes, specify:

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    Additional Medical Information:

    For your safety and the well-being of your unborn child, we strongly recommend postponing any tattooing/ scalp micropigmentation procedures until after the birth of your baby, due to potential risks including increased bleeding, infection, and uncertain effects of dye chemicals on fetal development.

    Are you pregnant?

    Have you been prescribed antibiotics before dental or surgical procedures?

    Do you have any cardiac valve diseases?

    Please provide any additional medical information or conditions that the body art practitioner should be aware of: 

     

    Client's Signature:

    Date: