Can we get your full name please?
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Thank you [s1] Now your date of birth please! (DD/MM/YY)
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Thank you [s1] Now can we have your full address
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Thank you [s1] Your Mobile number (don't worry, we don't share it with anyone)
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Can we have your e-mail address
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Thank you. Now we need to ask you some medical questions. Please read though and answer them with as much detail as you can.
Continue
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Do you suffer from any Heart conditions or Angina?
Yes
No
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Can you please discribe your Heart Conditions/Angina, and let us know of any mediacation you are taking for it?
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Do you suffer from Blood Pressure Problems?
Yes
No
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Can you please name/discribe your Blood Pressure problems, and let us know of any mediacation you are taking for it?
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Do you suffer from Hemophilia or any other Blood Clotting Disorders?
Yes
No
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Can you please discribe your Hempohilia or any Blood Clotting Disorders you have, and let us know of any mediacation you are taking for it?
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Do you suffer from or do you have any Blood Borne Virus or Communicable diseases? ( e.g. the Flu, hepatitis, HIV )
Yes
No
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Can you please discribe the Blood Borne Virus or Communicable disease and let us know of any mediacation you are taking for it?
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Do you suffer from any skin complaintes such as Psoriasis, Ecaema or Dermatits?
Yes
No
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Can you please discribe the skin complaint, and any mediaction or creams you are using for it?
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Do you have Diabetes?
Yes
No
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Can you tell us what type of Diabetes and tell us any medication your are taking for it?
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Are you allergic to anything? ( e.g. Anesthetics,, Jewellery or Hair Dye. )
Yes
No
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Can you plaese inform us of the subastance you are allergic to?
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Are you prone to fainting attacks?
Yes
No
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Please tell us how offten you are prone to fainting and if there are any triggers that you are aware of?
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Do you take any Blood thinning medicines? ( E.g. aspirin )
Yes
No
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Please give details of the Blood thinning mediaction you are taking!
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Do you take any regularly prescribed medication?
Yes
No
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Please give details of any prescibed medication you take?
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Could you be Pregnant?
Yes
No
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Please tell us how far along you are?
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Thank you, next please read the declaration and confirm all information is correct.
continue
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I declare that the information I have provided on medical history is correct to the best of my knowledge and that I am not currently under any 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 (i) the potential complications associated with the procedure and (ii) appropriate aftercare advice for the procedure. I agree that it is my responsibility to read this and follow the aftercare advice given until the treatment area is healed. I give consent to the operator to retain the details provided on this form for a period of two years from today.
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Name: [s1] Date of birth: [s2]

Address: [s3] Mobile Number: [s4]

E-mail: [s4a]


Medical History



Heart Condition/Angina:
[s6] Details: [s6a]
Blood Pressure Problems: [s7] Details: [s7a]
Hemophilia/Blood Clotting Disorders: [s8] Details: [s8a]
Blood Borne Virus: [s9] Details: [s9a]
Skin complaints: [s10] Details: [s10a]
Diabetes: [s11] Details: [s11a]
Allergies: [s12] Details: [s12a]
Fainting Prone: [s13] Details: [s13a]
Blood thinning Medication: [s14] Details: [s14a]
Other Medication: [s15] Details: [s15a]
Pregnant: [s16] Details: [s16a]

Tattoo undertaken/position:


I declare that the information I have provided on medical history is correct to the best of my knowledge and that I am not currently under any 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 (i) the potential complications associated with the procedure and (ii) appropriate
aftercare advice for the procedure. I agree that it is my responsibility to read this and follow the aftercare advice given until the treatment area is healed. I give consent to the operator to retain the details provided on this form for a period of two years from today.



Signed:


Operators Name:


Operators Signature:


Date and Time:


Thank you for filling in this form.