Please fill out the form below prior to your appointment at Kaymac Beauty. Microblading Medical Profile Form First Name * Last Name * Email * Phone Please check any of the following which pertain to you: Heart Conditions Allergies to Makeup Accutane Treatment Diabetes Epilepsy/Seizures Keloid/Hypertrophy Scars Stroke Chest Pains Dry Eyes Hepatitis/Jaundice/HIV Trichotillomania Shortness of Breath Alopecia Autoimmune Disorders Refractive Eye Surgery Glaucoma Cancer Kidney Disease Hyper Pigmentation Hypo Pigmentation Bleed Excessively To avoid any unforeseen complications, please answer the following questions:Are you under the age of 18? * Yes No If Yes, Please Have Parent/Guardian Sign Name Here Have you had any Asprin or blood thinning products within the last 7 days? * Yes No Any mood altering drugs within the last 8 hours? * Yes No Are you sensitive to Latex? * Yes No Have you had a chemical peel or laser treatment? * Yes No If Yes, When? Do you have problems with healing? * Yes No Previous problems with tattoos or has your physician advised you not to have tattoos? * Yes No Are you currently undergoing radiation or chemotherapy? * Yes No Are you currently using Retina-A or “Alpha Hydroxy” skin care products? * Yes No Are you allergic to any metal? * Yes No Have you ever had any permanent makeup procedures? * Yes No Immunosuppressive medication such as anti-inflammatory or steroids? * Yes No Are you allergic to topical antibiotic preparations or desensitizers? * Yes No Is there any history of skin diseases or remarkable skin sensitivities? * Yes No Are you presently taking Vitamins A and/or E in any form? * Yes No Are you pregnant or nursing? * Yes No Are you required to take antibiotics during dental or invasive medical procedures? * Yes No Please explain any checked question, list any other medical conditions, and list all your medications: Practitioner makes no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible reasons restricting you form receiving a tattoo, you must approve of the design and color before the application of your semi-permanent makeup. Sign Your Name * Today's Date * Captcha Submit If you are human, leave this field blank. Δ
