Client Pre-screening form CLIENT INFORMATION REQUIRED FOR PERMANENT COSMETICS/ VITILIGO/ AREOLAR TREATMENTS Fields or sections marked by an asterix (*) are required Personal Detail First name*: Last name*: Physical Address: Date of Birth* (dd/mm/yyyy): Occupation: Employer: Tel (W)*: Mobile*: E-mail*: Referred by: Description of intended procedure I am aware that the recommended procedure to be used is Micro Pigment Implantation. This is a form of tattooing used for the purpose of permanent make-up and the camouflaging of skin imperfections. Fees for the intended procedure I have been informed that this is a two-part procedure and for the best result a touch-up procedure is required 4 - 6 weeks after the original treatment as colour of the pigment used may fade. Second session (touch-up): Charged at 75% of original treatment price as per the current in-salon price list. I understand the above terms. NOTE: Appointments not cancelled 24 hours in advanced are charged at 25% of the treatment cost. Allergies List any drug, food, make-up or skin allergy that you have. This includes soaps, cleansing creams, earrings (other than gold) Novocain (local anaesthetic) or any derivatives of caine, latex, powders, menthol, petrolium, sulfa and zinc: (if you have no allergies type 'None' into the text box) * I understand that I could have an allergic reaction to the pigment / product & that my body may reject the pigment in some cases. I acknowledge that the manufacturer of the pigment applied requires spot testing & specifically disclaims any responsibility for adverse reaction to the applied pigment. I understand that spot testing may indemnify individuals who develop an immediate reaction to pigment, however, spot testing does not identify individuals who may have delayed allergic reaction to the pigment applied. Please select one of the two below* I agree to WAIVE allergy test: I waive a spot test prior to application & I agree to release the pigment suppliers and manufacturers from any & all liability related to allergic reaction to applied pigment.I want an allergy test (72hr waiting period for allergy to show) MEDICAL HISTORY (tick appropriate boxes) Do you have or have you had any of the following conditions? Abnormal Heart ConditionFainting / Dizzy SpellsCold Sores / Herpes SimplexGlaucoma (Loss of vision due to high blood pressure)Cancer / Radiation / ChemotherapyCorneal Abrasions (Chemical burn)Low Blood Pressure (Hypotension)Blepharoplasty (Surgery to repair/reconstruct eyelid)DiabetesTumours / Growths / CystsHigh Blood Pressure (Hypertension)Skin DisorderEye Surgery or Eye InjuryVisual DisturbanceCirculatory ProblemsCataractsHaemophilia (Prolonged Bleeding - blood doesn't clot properly)"Dry eyes"EpilepsyHepatitisAuto-Immune Disease (Destruction of tissue by immune system eg. HIV)Are you pregnant?Do you wear contact lenses?Do you smoke?Bleeding disorders?Broken capillary in the eyebrow area Have you recently undergone the following? Skin chemical peel within the last 3 months? ---YesNo Laser treatment within the last 3 months? ---YesNo Botox, fillers, dysport treatments within the last 3 months? ---YesNo Facial surgery within the last 3 months? ---YesNo Have you previously had the requested procedure done: ---YesNo If yes, by whom: What products were used: Where you satisfied: ---YesNo If not, why: When was the procedure done: Do you anesthetize easily with dental procedures: ---YesNo Are you prone to the following?* Keloid Scaring (severe elevated scarring) ---YesNo Hyperpigmentation (darkening of skin) from any injury ---YesNo Hypopigmentation (lack of pigmentation) from injury ---YesNo Are you or have you been in the care of a physician in the last 2 years? ---YesNo If yes, please specify what you are / were being treated for: List all medication you are currently taking, including Retina A, Glycol Acid, Ro-Accutane or any other form of oral acne medication, any blood thinning medication: (if you are not on any medication type 'None' into the text box) Are you using any eye drops or other ocular medication? ---YesNo Are you currently taking Aspirin or Ibuprofen? ---YesNo When was your last eye exam? Please confirm the eye physician's name: & contact number: Please select one of the two below* I have informed my cosmetic technician that I am in good health and not under the care of a physician for any of the relevant conditions as previously listed.I am currently under the care of a physician. If applicable: Medical Physician's Name: Practice Tel. No.: I am being treated for: By checking this checkbox you are agreeing to have filled in all information that is required by you and that this information is correct. Please note: Unless a message appears that you the form has been sent, it has not. Please re-check that you have filled in all required fields.