Colorwatch report form.qtxt

Colorwatch For VOLUNTARY reporting of adverse (migration) or
allergic reactions to pigments used in permanent makeup.
The AAM Safety Information and Adverse Event Reporting Program Mail to: PARR, 1087 Keolu Drive, Kailua, HI 96734
DClient ID
PARR: Pigment Adverse Reaction Report
A. Technician Information / Identifier
Phone Number
B. Patient (Client) Information
G. Suspected Pigment(s) / Inks: (list each pigment used)
Manufacturer
Doctors(s) Name(s) / Phone Number (s) / Specialty
C. Location of Adverse Reaction: (check all that apply)
H. Relevant Test / Biopsies / Lab Data (including dates)
Eyebrow
Cheeks
Scratch Test Positive
Granuloma with pigment
Eyeliner
Breast
Body (below neck)
Tissue Biopsy (Punch Biopsy)
Other:
Dr. Diagnosis (no biopsy)
D. Sensitivity “Spot” Test: (check all that apply)
Yes
Positive
Waived
Treatments Attempted: (check all that apply)
Negative
Location:
Kenalog® Injection Into Area
Decadron Ophthalmic
E. Description of Adverse Reaction:
Overtattoo: Kenalog®
Cortisone Pills/Shots
(check all that apply)
Overtattoo: Salt Solution
Surgery
Bleeding
Burning
Overtattoo: Chemicals (acids)
Dermabrasion
Swelling/Fluid
Dryness/Flaking Tender to touch
Protopic (Elidel) or Aldara®
Laser: LP Erbium or CO2
Skin Raised/
Bumps in skin
Scabbing
Puff Paint
Cream: Steroid or Kenalog®
Laser: Other (describe)
Infection
Cracking
Migration
Current Status: (check all that apply)
Describe Event or Problem: Send Pictures if Possible
Undergoing Treatment
Lawsuit v. Technician
Disability
Lawsuit v. Manufacturer
Disfigurement
Reported to Insurance Co.
Problem better
Other (Describe)
Problem worse
Problem Ongoing
K. Final Diagnosis and Outcome

L. Reporter (check all that apply)
Reporter Name
Reporter Address
Reported To: (check all that apply)
Manufacturer
Distributor
M. Health Care Professional
Check this box if you do NOT want your
identity disclosed to the manufacturer
No Occupation

Source: http://www.micropigmentation.org/allergic_reactions/Colorwatch_Report.pdf

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