Tattoo Forms | MK WELLNESS

First name

Last name

Email

Phone

I agree to be contacted by phone or email.

Please tick any of the condtions you have:

Abdominal/ Digestive problems

Allergies

Arthritis

Asthma or lung conditions

Blood clots/Thrombosis

Cancer / Tumors

Chronic Fatigue

Chronic pain

Depression

Diabetes

Fatigue

Fibromyalgia

Headaches or migraines

Hearing problems

Heart, circulatory problems

Hernias

High / Low blood pressure

Infectious disease

Lymph node removal

Motor vehicle accident / trauma

Muscle or joint pain

Muscle, bone injuries

Numbness or tingling

Phlebitis

Pregnancy

Rash, athletes foot/tinea

Seizures

Skin disorders

Stroke

Varicose veins

Vision problems/contact lenses

Pigmented lesions

Recent cosmetic injectable treatments

Recent IPL or Laser

Post- surgery wound healing

Open skin

Undiagnosed lumps

Prone to Keloid scars

HIV

History of eczema

Psorisis and other chronic conditions

History of actinic solar keratosis

History of herpes simplex infections

Uncontrolled diabetes

On anticoagulant medications

Hemophilia

Other

None

Tattoo related contraindications needing medical approval prior to treatment.

Current medications (including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies):

Do you smoke?

Yes

No

Is your skin oily?

Yes

No

Do you have your period at the moment?

Yes

No

Do you have a tendancy to develop dark spots on the skin from wounds or sun?

Yes

No

Do you scar easily from minor skin injuries?

Yes

No

Do you have hepatitis?

Yes

No

Do you have a pacemaker?

Yes

No

Have you had any problems with healing after permanent make-up or anyother cosmetic treatment?

Yes

No

Are you currently or have you ever been on accutane for acne treament? (isotretinoin)

Yes

No

Are you currenty on auto-immune therapy?

Yes

No

Are you currently undergoing radiotherapy or chemotherapy?

Yes

No

Are you using topical retinin? A (tretoin) for acne?

Yes

No

Have you had facial surgery in the last 3 months?

Yes

No

Are you allergic to hair dye?

Yes

No

Are you allergic to latex?

Yes

No

Are you taking fish oil or omega 3 fatty acids?

Yes

No

Are you taking fish oil or omega 3 fatty acids?

Yes

No

Pre treatment instructions

Do not drink any coffee, alcohol or energising drinks on the day of treatment.

Do not take Asprin, Niacin, Vitamin E or Ibuprofen 24 hours before the treatment.

Do not take omega 3 (fish oil) 1 week before your treatment.

Do not tan or have intense sun exposure 3 days before treatment.

No waxing 3 days before treatment.

No chemial peels, dermabrasion, laser or any intense treatments 2 weeks before your treatment.

Shower and fix your hair before your treatment as you can't get your eyebrows wet for 5 days after.

Optional Apply Emla Cream 2 hours before you come in. Save half of the tube for your second session.

Post treatment instructions

After 30 minutes of the procedure, wash the area with cold and neutral soap.

Perfom this procedure 3x per day for 5 days.

Do not expose the eyebrows to the sun for 7 days and avoid the sun for the next 23 days.

Do not bathe in the sea/pool/sauna for 7 days.

Always sanitise your hands before touching the pigmented area.

Avoid wearing makeup for 7 days.

Do not scratch or remove scabs.

Book your touch-up no sooner than 30 days after the first session.

I agree to for the therapist to use Heidi Help - a note transcribing AI.

I agree to the terms & conditions and give consent for my treatment.

I understand the potiential risks and adverse reactions of the procedure.

Signature

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