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Gender
MaleFemaleOther

Medical History
Do you currently have, or have you ever had, any problems with the following?
For those where you have ticked 'yes', please explain in the text box below, and for surgeries/treatments, please provide date of last surgery/treatment.

Keloid or hypertrophic scars?
YesNo
Hyperpigmentation?
YesNo
Skin disorder(s)?
YesNo
Cold sores or shingles?
YesNo
Bleeding disorder?
YesNo
Radiation treatments?
YesNo
Chemotherapy?
YesNo
Wear contact lenses?
YesNo
Cataract surgery?
YesNo
Glaucoma?
YesNo
Neurological disorder?
YesNo
Diabetes?
YesNo
Heart disease?
YesNo
Lung disease?
YesNo
Hepatitis or other liver disease?
YesNo
Rheumatologic disorder?
YesNo
HIV/AIDS?
YesNo
Are you currently pregnant?
YesNo
Post-menopausal?
YesNo

Cosmetic History
Have you had, or are you planning, any of the following treatments?
For those where you have ticked 'yes', please explain in the text box below.
Skin laser treatments?
YesNo
Chemical skin peels?
YesNo
Botox injections?
YesNo
Dermal fillers?
YesNo
Brow or face lift?
YesNo
Accutane?
YesNo

Are you currently taking any blood thinners, aspirin, anti-inflammatories or other anti-platelet medication?
YesNo

Do you wish to donate blood within one year of a micropigmentation procedure?

Are you planning an MRI in the near future?
YesNo

Are you allergic to any medications and/or products?
YesNo

Attachments


Disclosure
Have you discussed the issue(s) surrounding the aspect(s) of your appearance that concerns you with a physician, therapist or psychologist?
YesNo

I acknowledge that any information contributed by me on this Client Personal Record and Medical History Form is true; to the best of my knowledge and that the present condition of the area that has been treated or will be treated is stated on this record. I understand that the treatment provided will rely, in part, on the medical history I have provided, and that if this medical history is inaccurate this may negatively affect my treatment and/or result in complications. I consent to the submission and storage of my personal health information on the secure Cosmetic Transformations server. Yes

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If you are having difficulties uploading your photos or completing the form, or if you feel nervous and just need to speak with us, please call: 1 705 931 5955.

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