Cosmetic Tattoo/Microblade Client History & Disclosure Form

Please complete this form in preparation for your appointment. Any information that you provide us with will be treated as confidential and will only be accessed by BrowGame Pty Ltd staff.

Full Name
D.O.B
Mobile #
Postcode
Email
Emergency Contact
Referred by (name)
Found us by

COSMETIC TATTOO PROCEDURE (S) DESIRED

Eyebrows - Full/New Shape  X 
Top Eyeliner  X 
Bottom Eyeliner  X 
Existing tattoo colour refresh  X 
Eyebrows - single scar coverage (single treatment)  X 
Thick Top Eyeliner  X 
Bottom Lash Enhancement Liner  X 
Patch Test  X 

Please describe what result you are hoping for from your treatment?

PLEASE READ EACH SECTION AND MARK THOSE WHICH APPLY TO YOU

1. TICK if you have ever had an allergic reaction to any of the following and describe what happened.

Lanolin  X 
Lidocaine/Lignocaine/Novocaine  X 
Foods (specify below)  X 
PABA  X 
Sunscreen  X 
Hair dye/Henna/Cosmetics (specify below)  X 
Latex/Rubber  X 
Previous tattoo ink or pigment  X 
Metals  X 
Dental/local anaesthetic injections  X 
Other drugs/medications (specify below)  X 
Other (specify below)  X 

Details/Reaction

2. Mark any of the conditions below that apply to you, past or current. Whilst some may seem irrelevant to the cosmetic tattoo treatment you are having, we ask these questions to help improve your comfort during the treatment, and manage any safety/health issues correctly.

Glaucoma  X 
Cataracts  X 
Blurred Vision  X 
Any other eye conditions  X 
Contact Lenses  X 
Thyroid conditions (some medications may cause faster fading of pigments)  X 
Dry Eyes  X 
Alopecia Universalis (total)  X 
Alopecia Areata (local)  X 
Do you pull out lashes and/or eyebrows compulsively? (trichotillomania)  X 
Eyebrow tinting  X 

Date of last service
Eyelash tinting  X 
Date of last service
Eyelash Extensions(Relevant for eyeliner only).  X 
Date of Removal.

(Eyelash Extensions MUST be removed at least 3 days prior to eyeliner tattoo)

Collagen/Restalyn/Botox or other injections.  X 

Location(s)

Dates
Gortex/fat transfer injections.  X 

Location(s)

Dates
Laser/IPL /Fraxel/Skin Needling treatments.  X 

Location(s)

Dates
Any other tattoo treatments (cosmetic or artistic) on your face & body?  X 

Tattoo Artist/Studio/Location  X 

Dates of Tattoos  X 
Any problems?  X 

Do you go to the solarium/tanning bed/tan outdoors regularly?  X 
Are you currently tanned in the area to be tattooed?  X 
Do you consider your skin to be oily/visible pores?  X 
Do you currently use Retin A or products containing Retin A or Glycolic Acid? Where?  X 

Are you currently using any Glycolic Acid or other AHA skin products?Where?  X 

Have you ever had a facial chemical peel? Dates  X 
Start Date



What Type
Do you have any keloid or hypertrophic/raised scars? Where?  X 
Do you bleed easily?  X 
Do you bruise easily?  X 
Do you have any other active dermatological disorders, such as Eczema, Dermatitis, Psoriasis, Rosacea, Acne and Skin Cancers?  X 

Please specify
Are you a smoker?  X 
High Blood Pressure  X 
Low Blood Pressure  X 
Taking blood thinners or anticoagulants such as Aspirin, Ibuprofen, Coumadin, Alcohol, Q10?  X 
Diabetic (A letter from your Doctor is required before treatment can proceed)  X 
Haemophilia or other clotting disorders (prolonged bleeding)  X 
Epilepsy/Seizures. Describe

Claustrophobia/fear of closing eyes for prolonged period  X 
Spinal problems/back issues  X 
Currently undergoing treatment for Cancer  X 
In remission from Cancer Months/years post remission  X 

Pregnant or planning to become pregnant before treatment  X 
Breastfeeding  X 
Mitral valve prolapsed or valve implants  X 
Undergoing IVF treatment  X 
Pacemaker  X 
Heart condition of any kind  X 
Taken Accutane/Roaccutane within the last 6 months  X 
HIV/Autoimmune disorders of any kind. Describe:  X 

NOTE: You are not legally required to disclose if you are positive for HIV or Hepatitis. We follow standard precautions as prescribed by NSW Health to ensure that the procedure is safe with no risk of transmission of blood borne disease or infection to/from any client. We ask this questions because SOME medications and treatments of HIV/Hepatitis and Cancer can interact negatively with the procedure, and your health and safety are of our highest concern. Please consult with your medical specialist regarding this treatment.

Hepatitis  X 
Blood Transfusion.  X 

Recent Surgeries (within last 12 months)  X 
Planning facial cosmetic in the near future (describe)  X 
Any other medical condition  X 

Under a physician's care for any condition.  X 

Physicians Name:-
Phone:-

List any medications, prescription and non-prescription (including supplements/non-Western/herbal medicines) that you have taken in the last four weeks:

I have answered the above questions truthfully and honestly.

CLIENT NAME:
DATE:
PRACTITIONER SIGNATURE: DATE: