Confidential Medical Profile

First Name

Last Name

Phone *

Email *

Medical Profile

Are you currently under the care of a physician? *

Yes

Physicians Care - If yes, please specify.

Are you currently under the care of a dermatologist? *

Yes

Dermatologist Care - If Yes, Please specify

Is there any history of skin diseases or remarkable skin sensitivities? *

Yes

Do you have a history of erythema ab igne, which is a persistent rash produced by prolonged or repeated exposure to moderately intense heat or infrared irritation? *

Yes

Do you have a history of cold sores, herpes, or fever blisters? *

Yes

Do you wear contact lenses? * If yes, I understand they must be removed during my eyeliner procedure and should not be replaced until the next day. *

Yes

Do you have problems healing? *

Yes

Are you currently undergoing radiation or chemotherapy? *

Yes

Are you pregnant or nursing? *

Yes

Other Conditions: Please list any other medical conditions or issues not addressed above:

Medications & Herbal Supplements

Medications: Please list any medications you are currently taking. Including but not limited to any mood altering or anti-depression medication, birth control pills, hormones, etc. *

Are you on any immunosuppressive medications such as anti-inflammatories or steroids? *

Yes

Herbal Supplements: What herbal supplements do you use regularly? *

Are you currently taking any Vitamins A or E in any form? *

Yes

Consent

By submitting this form, I acknowledge, understand and agree that:

The staff with Julie Michaud does not practice medicine, does not accept health insurance, and have made no representation to the contrary; the information provided on this form is accurate and complete to the best of my knowledge, and that the staff with Julie Michaud is not responsible for complications or problems arising from any incorrect or omitted information.
The staff with Julie Michaud will use the information provided above to assess my suitability for the proposed services.
I have disclosed all medications and/or drugs I am taking either prescription or non-prescription and their purpose or indications.
All the information provided on this form is accurate and up to date. I agree to inform Julie Michaud of any changes to my health that may affect this information.