PMU Medical Screening Form

Please fill this out prior to your treatment

First name

Last name

Birthday

Day

Month

Year

Are you over 18 years old?*

Yes

No

Are You pregnant or Breast feeding ?*

Yes

No

Do you have any allergies ?*

Do you have any imminent Holiday Plans ?

Are you prone to keloid scaring ?

Yes

No

Do you suffer from any haemophilia ?*

Yes

No

Do you knowingly have any infectious diseases or mortal valve prolapse ?

Yes

No

Do you knowingly have any blood disorders ?

Yes

No

Do you suffer from coldsores ?*

Yes

No

Do you have Diabetes?

Yes

No

Do you have any auto immune conditions that associate with wound healing?

Yes

No

Are you taking any medications ?

yes

No

Have you been diagnosed with cancer within the last 12 month or undertaken any chemotherapy or Radio therapy ?

Yes

No

If you have answered yes to any of the above , please provide details.

bottom of page