Health Screening Form for Cosmetic Tattoo/Microblade treatments at Lady Lash Australia - Cosmetic Tattoo & Microblading - BROWGAME | Sydney Cosmetic Tattoo

Once you have decided to make an appointment with us, please firstly complete the confidential health screening form below. This is to ensure that we have flagged any potential issues, and provided you with advice if you need to alter your skincare prior to the appointment or seek medical advice.

Please note - if this questionnaire is not completed ahead of time, we may not be able to proceed with your treatment on the day of the appointment. Your health is our highest priority, and we need to ensure that the treatment is safe and appropriate for you.

If you're unsure or this form is not working for you, feel free to contact us on 0488 855 503 - we're more than happy to help!

Please also ensure that you have also read and understand all of our Cosmetic Tattoo Preparation Guidelines, so that you receive the best results possible from your treatment.

CONFIDENTIAL HEALTH SCREENING FORM - BROW GAME

Full Name:

DOB:(dd/mm/yyyy)
Mobile:
Email:

What treatment/s are you interested in?

Eyebrow Tattoo (microblade, powder, combination etc)Eyeliner TattooLip TattooRefresh of tattoo done previously at Browgame

Do you have an existing cosmetic tattoo in the area?

YesNo
(Please answer YES regardless of how faded, we need to know of any existing pigments in the skin, even if decades ago!)

YOUR HEALTH

Medication, including some supplements, can affect the healing and colour outcome of your procedure. It is important to be completely honest and detailed if you are taking any medication, or if any of the following applies to you:

Recent surgeries (in previous 6 months)	YesNo
Diabetes Type 1	YesNo
Diabetes Type 2	YesNo
Keloid scarring	YesNo
Epilepsy	YesNo
Moles on the area	YesNo
High blood pressure	YesNo
Alopecia	YesNo
Any heart condition/prior heart condition (regardless of how minor)	YesNo
Eczema or dermatitis on face	YesNo
Blood clotting issues	YesNo
Hyperpigmentation	YesNo
Hepatitis	YesNo
Anxiety	YesNo
Claustrophobia	YesNo
Cold sores/history of	YesNo
Thyroid disorders	YesNo
Liver disease	YesNo
Autoimmune disease	YesNo
Rosacea	YesNo
Sunburn in previous 2 weeks	YesNo
Trichotillomania	YesNo
HIV	YesNo
Anaemia	YesNo
Cancer (currently being treated)	YesNo
Cancer (in remission)	YesNo
Do you smoke?	YesNo

Allergies

Please list ALL/ANY - including cosmetics, foods, dyes, medications etc

Have you had previous reaction/problem with anaesthetics	YesNo
Are you currently pregnant, breastfeeding, planning to conceive or undergoing IVF/Fertility treatment	YesNo

YOUR MEDICATIONS

Are you using?

Opioid Medication (Endone, Methadone, Tremadol, Oxycontin)	YesNo
Chemotherapy/ Radiation Therapy	YesNo
Tamoxifen	YesNo
Prednisone	YesNo
Thyroxine	YesNo
HRT	YesNo
Roaccutane/Accutane (within past 12 Months)	YesNo
Antibiotics / Doxycycline	YesNo
Prescription Vitamin A	YesNo
Warfarin/ Heparin/ Blood Thinners	YesNo

Other Medications

Vitamins / Fish Oils or Herbs
Details

YOUR SKINCARE
In the last 6 months, have you had any of the following?

Facial laser/IPL	YesNo
Facial Skin Needling	YesNo
Facial Filler	YesNo
Muscle relaxants/anti wrinkle injections	YesNo
Chemical peels	YesNo

Does your current skincare involve any of the following?

AHA's (alpha hydroxy acids) including glycolic and lactic acids	YesNo
BHA's (beta hydroxy acids) including salicylic acids	YesNo
Vitamin A	YesNo
Vitamin C	YesNo
Benzoyl Peroxide	YesNo
Hydroquinone/Kojic Acid	YesNo
Any other whitening or bleaching skin product	YesNo

EYELINER

Do you wear contact lenses?(You will need to be removed on the day)	YesNo
Have you had any eye surgery?	YesNo
Are you using lash enhancing serums? (You will need to stop 3 weeks prior)	YesNo
Do you/have you had glaucoma?	YesNo
Do you have cataracts?	YesNo
Do you have dry eyes?	YesNo
Do you have any recent/current eye infections?	YesNo

I certify that the information I have provided is true and correct to the best of my knowledge. YesNo