APPLICATION FOR CONSIDERATION FOR A FREE MICROPIGMENTATION TREATMENT

DOB

Full Name

Address

Best telephone number to reach you on

Email Address

Are you applying for yourself or someone else? Are you applying for yourself or someone else? Myself Someone else

If someone else, have they given you permission? If someone else, have they given you permission? Yes No

Are you (or the person you are applying for) over the age of 18? Are you (or the person you are applying for) over the age of 18? Yes No

Have you ever had Semi/Permanent Makeup before? Have you ever had Semi/Permanent Makeup before? Yes No

Have you ever had Semi/Permanent Makeup to the area you would like treated? Have you ever had Semi/Permanent Makeup to the area you would like treated? Yes No

How long ago? ( months)

Please advise which treatment you would like:

Please advise why you would like this treatment:

Please give more info as to what has caused the scarring:

Do you have any scar tissue in or around the area you would like treated? Do you have any scar tissue in or around the area you would like treated? Yes No

Do you have any medical conditions? Do you have any medical conditions? Yes No

How old is the scar tissue?

Please advise:

Are you taking any medications? Are you taking any medications? Yes No

Please advise which medications:

Please list surgical procedures within last 5 years:

Have you had surgery within the last 6 months? Have you had surgery within the last 6 months? Yes No

If answered yes, please advise

Do you have any mobility issues? Do you have any mobility issues? Yes No

Please advise:

Do you smoke? Do you smoke? Yes No

How many units of alcohol do you drink per week?

What are your present circumstances?

Are you able to attend a NO OBLIGATION FREE CONSULTATION at India Gabrielle’s clinic in Bexhill? Are you able to attend a NO OBLIGATION FREE CONSULTATION at India Gabrielle’s clinic in Bexhill? Yes No

Are you able to attend Monday to Friday? Are you able to attend Monday to Friday? Yes No

Do you have active cold sores or warts? You must inform India Gabrielle in advance of treatment if you have any history of herpes simplex. It does not mean that you can not have treatment - just that you need to be given the relevant advice to help prevent an outbreak. Do you have active cold sores or warts? You must inform India Gabrielle in advance of treatment if you have any history of herpes simplex. It does not mean that you can not have treatment - just that you need to be given the relevant advice to help prevent an outbreak. Yes No

Do you use Retin A/Retinova/Retinol products? Do you use Retin A/Retinova/Retinol products? Yes No

Do you have open wounds, or recent scars? Do you have open wounds, or recent scars? Yes No

Do you have any skin conditions such as psoriasis, eczema, dermatitis, lichen planus, inflammatory rosacea in area to be treated, severe acne, frequent rashes or any other skin conditions, infection or reactions? Do you have any skin conditions such as psoriasis, eczema, dermatitis, lichen planus, inflammatory rosacea in area to be treated, severe acne, frequent rashes or any other skin conditions, infection or reactions? Yes No

Do you have sunburn, or recent moderate to heavy tanning? Do you have sunburn, or recent moderate to heavy tanning? Yes No

Do you have excessively sensitive skin? Do you have excessively sensitive skin? Yes No

Please advise of all allergies:

Do you have a history of allergies? Do you have a history of allergies? Yes No

Please advise what you are allergic to

Do you have any known sensitivities to any of the components of this treatment (Including metals)? Do you have any known sensitivities to any of the components of this treatment (Including metals)? Yes No

Have you taken Roaccutane or any Corticosteroids within the past year? Have you taken Roaccutane or any Corticosteroids within the past year? Yes No

Have you been treated with chemotherapy or radiation therapy? Have you been treated with chemotherapy or radiation therapy? Yes No

Please advise when or how long ago your last treatment was

Do you have Keloid Scarring? Do you have Keloid Scarring? Yes No

Do you have an auto immune disorder? Do you have an auto immune disorder? Yes No

Are you pregnant or breast feeding? Are you pregnant or breast feeding? Yes No

Are you currently suffering from any current illness? Are you currently suffering from any current illness? Yes No

Have you had any injectable treatments such as Botulism or Hyaluronic Acid based semi permanent fillers within the last 6 weeks? Have you had any injectable treatments such as Botulism or Hyaluronic Acid based semi permanent fillers within the last 6 weeks? Yes No

Do you have permanent fillers (those with permanent fillers should not be treated in the area where present)? Do you have permanent fillers (those with permanent fillers should not be treated in the area where present)? Yes No

Is there anything else that you would like to say? If so, please advise:

Confirmation Confirmation Please confirm that all of the above statements are true