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PMU Brow and Body Artist

Pre-appointment Medical Health Form

Date of Birth
Day
Month
Year
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?
Yes
No
Have you received chemotherapy or radiation treatment in the last year?
Yes
No

Allergies

Have you ever had an allergic reaction to any of the following?
Have you ever had a dental injection to numb your mouth?
Yes
No
Are you presently pregnant or breast feeding? Yes/No (We can’t perform treatment if you are pregnant or breastfeeding)
Yes
No
Do you have a MRI scan scheduled in the next 3 months?
Yes
No
Laser or IPL scheduled in the next 3 months?
Yes
No
Do you give blood?
Yes
No
Prior to dental procedures do you receive antibiotic therapy?
Yes
No
Have you had Botox or other injectables?
Yes
No
Please tick the appropriate boxes if any of the following conditions relate to you. If you have any medical conditions listed in this section you will need GP consent before we can carry out any semi permanent make up treatment.
Please tick the appropriate boxes if any of the following conditions relate to you. GP Consent not needed.
Have you ever had semi permanent make up before?
Yes
No
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If you have any medical condition or you are currently under a medical consultant or general practitioner and taking medication we will require you to bring a GP consent letter, prior to us performing semi permanent cosmetic treatment.

For re-touch procedure only (please tick one of the following boxes)

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