Health form
Your Full Name (required)
Your Email (required)
Your phone number
Date of birth
Home address
Side of the body
Tattoo or Piercing or Laser?
Operator name
Do you currently suffer from or have you ever suffered from any of the following? If yes please describe the details
Heart condition/Angina
Blood pressure problems
Epilepsy/Seizures
Haemophilia/Blood clotting disorders
Blood borne virus e.g. Hepatitis
Skin Complaints e.g. eczema
Diabetes
Allergic Response
Are you prone to fainting attacks?
Do your regular take any blood-thining medicines e.g. aspirin
Do you take any regular prescribed medication?
Could you be pregnant?
How did you find about us?
I declare that the information I have provided on medical history is correct to the best of my knoweldge that I am not currently under influence of drugs or alcohol. I hereby give consent for the procedure detailed above to be carried out by the named operator. I confirm that i have been provided with written information on the potential complication associated with the procedure and i appropriate after care advice for the procedure. I agree that it is my responsibility to read this and follow up the aftercare advice given until the treatment area is healed. Answer Yes or No.
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