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THE GOODFACE MEDICAL FORM

Preferred Pronoun*

Name:*

Date*(MM/DD/YYYY)

Procedure(s):*

Email: *

Address:*

Same as above

Phone:*

DOB:*(MM/DD/YYYY)

Emergency Contact:*

Phone:*

Do you have or previously had any of the following:

History of MRSA*

Botox and/or Filler*

Yes

Diabetes*

Yes

Hepatities A B C*

Yes

Forehead Lift / Brow Lift*

Yes

Cardiac Valve Disease*

Yes

Hemophilia or other bleeding disorders*

Yes

Blood clotting disorders*

Yes

Alcoholism*

Yes

Herpes at proposed procedure site*

Yes

Pregnant now / Breastfeeding now*

Yes

Autoimmune disorder*

Yes

Immunosuppression*

Yes

Any active infection or inflammation at proposed procedure site*

Yes

Skin diseases / Skin lesions*

Yes

Seizures*

Yes

Keloid scarring*

Yes

Oily skin / Sensitive skin*

Yes

Cancer*

Yes

Accutane or acne treatment*

Yes

Chemotherapy / Radiation*

Yes

Tan by booth or sun*

Yes

Tumors/Growth/Cysts in or near proposed procedure site*

Yes

Difficulty numbing with dental work*

Yes

Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin, etc.*

Yes

Allergic reaction to any medications such as Lidocaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E, Acetate, ect.*

Yes

Allergies to latex or antibiotics*

Yes

Do you use skin care products containing Retin-A, Glycolic Acid, Retinol, Alpha Hydroxy, Vitamin C, or Niacinamide?*

Yes

Prior to dental work, I am required to take antibiotics*

Yes

Any allergies or previous adverse reactions to medication? Please list:*

Any other medications you are taking, including over-the-counter, herbal supplements or vitamins? Please list:*

Are you under the care of a physician?*

Yes

Please list all previous surgeries:*

Please list all current illness:*

Do you have ALS / Lou Gehrig's Disease*

Yes

Do you have Myasthenia Gravis?*

Yes

Do you have Lamber Eaton Myasthnia Syndrome?*

Yes

Do you currently smoke?*

Yes

Have you ever used Accutane or Spironolactone?*

Yes

I give consent and authorization to the tattoo artist from THE GOODFACE to perform the treatment we have discussed, using Topical Benzocaine/Lidocaine/Tetracaine Cream, and will him/her and his/her staff harmless from any liability that may result from this treatment.

I understand the tattoo artist will take every precaution to minimize or eliminate negative reactions as much as possible. I do understand that, very rarely, permanent damage occurs. I have given an accurate account of any over-the-counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir, or tranquilizers. I have not had any chemical peels, skin care procedures, laser treatments, or infections that I have not disclosed to my tattoo artist. I am not ingesting, or using topically, any other over-the-counter product or prescription medication/agent that has not been disclosed to my tattoo artist. I have informed my tattoo artist if I am pregnant or lactating. I am over the age of eighteen (18), or have written consent from a physician to proceed as a minor. I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, diabetes, any autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment. I have read and understand all the above information regarding my treatment, and the information I provided is true and accurate to the best of my knowledge. I am aware that this procedure does not guarantee specific results.

Signed:*

Click to sign

Date*(MM/DD/YYYY)

2022 Medical Form_BOOK