BROWS BY OUIDA

Brows by Ouida @ Salon Cheveux

 

Client Medical History Form - Date __________________________________

Name  ___________________________________  Birthdate_____________Age______________

Address__________________________________________________________________________             

Phone_______________     Email ____________________________________         

Emergency Contact Person     Phone     Do you have or previously had any of the following: (Circle YES or No) 

YES  NO  History of MRSA 

YES  NO  Botox (Last treatment        ) YES  NO  Diabetes 

YES  NO  Hepatitis A B C D

YES  NO  Forehead/Brow Lift YES  NO  Easy Bleeding 

YES  NO  Facelift 

YES  NO  Alcoholism 

YES  NO  Abnormal Heart Condition 

YES  NO  Take medication before dental work 

YES  NO  Chemical Peel (Last Treatment             ) YES  NO  Pregnant now – Breastfeeding now 

YES  NO  Brow Lash Tinting 

YES  NO  Autoimmune disorder YES  NO  Oily Skin 

YES  NO Cancer (Year.        ) YES  NO  Accutane or acne treatment YES  NO  Chemotherapy/ Radiation YES  NO  Tan by booth or salon 

YES  NO  Tumors/ Growth/ Cysts 

YES  NO  Difficulty numbing with dental work 

YES  NO  Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc 

YES  NO  Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc        YES  NO  Allergies to metals, food, etc      

YES  NO  Any diseases or disorders not listed      

YES  NO  Do you use skin care products containing Retin A, Glycolic Acid, or Alpha Hydroxyl? Please list any medications you are taking    

 

   I agree that all the above information is true and accurate to the best of my knowledge 

 

 

Signed                                                                                         Date