Medical Health Form

Please note: Any clients who have medical conditions who are under the consultant or the GP and are on medication will need GP referral. If you do not have GP referral we won’t be able to perform the procedure.

Medical Health Form

Consent Form

This field is for validation purposes and should be left unchanged.
Name(Required)
Address(Required)
Have you taken any of the following in the last 2 days:(Required)
Have you received chemotherapy or radiation treatment in the last year?(Required)
Allergies - Have you ever had an allergic reaction to any of the following:
Have you had a dental injection to numb your mouth?(Required)
Are you presently pregnant or breast feeding? (We can’t do treatment for pregnant or breastfeeding women)(Required)
MRI scan scheduled in the next 3 months?(Required)
Laser or IPL scheduled in the next 3 months?(Required)
Do you give blood?(Required)
Prior to dental procedures do you receive antibiotic therapy?(Required)
I have had Botox or other injectables.  (Required)
(If yes you will need GP referral)
(A) I understand that a skin test can determine within 24 hours if I will have a reaction to the product, but that it is inconclusive as to whether I will have an allergic reaction at any time in the future. I choose the waiver my option to an allergy test and wish to proceed. (B) I have undergone/been offered an allergy test prior to my initial treatment and thereby release the technician from any liability related to any allergic reaction to applied pigment or other products, or at a later date.
I have read and understood the section:(Required)
Please fill out the following table with a tick to indicate if any of the following relate to yourself. If you have any of these medical conditions in first column you will need GP referral. Medical conditions:
Other conditions:
Have you had semi permanent make up before?(Required)
I give my consent for semi-permanent make up work to be carried out, which is undertaken at my request:
I give consent for my photos to be advertised on social media, websites, shown to other clients etc.

My procedure has been completed to my satisfaction and I have been given the opportunity to discuss any immediate concerns with my technician. I fully understand my aftercare instructions.
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