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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

dairymed.com

Northern Valley Dairy Production Medicine Center 900 N Wabasha, Plainview, MN 55964 (507) 534-4356, 1-888-534-4026 Dehorning and castration are necessary procedures in the cattle business. We all know that cattle have to be dehorned to protect animal and workers. We also know markets demand meat from steers, and that young bulls can be dangerous to humans. Our industry is coming under more a

pacificmedicalgroup.com

H A N D B O O K Managing Your Coumadin works by partially blocking the re-use of Vitamin K in your liver. Vitamin K is needed to make clotting factors that help the blood to clot and prevent bleeding. By blocking the Vitamin K, coumadin reduces the body’s ability to make clots and can stop harmful clots from forming or from getting larger. Coumadin does not break up existing blood clots. C

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