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ACCUEIL
TATOUAGE
DÉTATOUAGE
LE PUR
CILS
ONGLES
Plus

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MEDICAL ASSESSMENT QUESTIONNAIRE

LAST NAME/FIRST NAME :

LAST NAME/GUARDIAN'S FIRST NAME :

DATE OF BIRTH : * required

DO YOU HAVE ANY HEALTH CONDITIONS OR CONCERNS THAT OUR PROFESSIONALS SHOULD BE AWARE OF FOR YOUR CARE?

IF YES, PLEASE PROVIDE DETAILS:

Allergies (e.g., latex, petroleum jelly, metals, ink) *

Yes

Pregnant / Possibility of pregnancy *

Yes

Dermatological condition (e.g., melanoma, psoriasis, eczema, shingles, acne) *

Yes

Autoimmune disease (e.g., multiple sclerosis, rheumatoid arthritis) *

Yes

Blood-borne disease *

Yes

Condition affecting the immune system (e.g., cancer, stem cell transplant) *

Yes

Heart disease / pacemaker *

Yes

Diabetic *

Yes

Medications and/or treatments (e.g., Accutane, Aspirin, anti-inflammatory drugs, blood thinners, retinol, chemotherapy) *

Yes

Other condition(s) or medical history (e.g., abnormal scarring, epilepsy) *

Yes

Consumption habits (e.g., tobacco, drugs, alcohol). If yes, frequency. *

Yes

AGREEMENT AND SIGNATURES

**I understand that the accuracy and updating of the information provided in my health assessment are essential to ensure my health, safety, and optimal results regarding the services provided by the Artist prior to each of my appointments.**

Client Signature

Guardian Signature

Artist Signature

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*POST-TREATMENT CARE FORM*

CONTACT

Lieu

535 Bd Laurier O

Sainte-Marie-Madeleine,

QC J0H 1S0

tatouageroy@hotmail.com

Tél : 450-600-1264

Des questions ?

Appelez-nous au 450-600-1264 ou laissez-nous un message :

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Bilan de Santé Roy Tatouage

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Health Assessment

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