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25 36. Currently under doctors care? Yes No 37. Trichotillomania. Yes No (Compulsively pulls our lashes,brows,and other hair which grows out of the body) 38. Brow or lash tinting Yes No When was the last tint performed? 39. Contact lenses Yes No Please remove for eyeliner procedure and resume wear after i week or until after permanent eyeliner has healed and sealed itself. 40. Alopecia Yes No Which kind? 41. Amyloidosis(autoimmune) Yes No If yes,then you are cannot receive permanent makeup. 42. Optical Herpes Yes No If yes,then you cannot receive permanent eyeliner. 43• Mitral Valve Prolapse Yes No 44. Cardiac Valve Disease Yes No If yes,then you are cannot receive permanent makeup. 4.PATCH TEST WAIVER The Releasor acknowledges that the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments.The Releasor understands spot testing may identify individuals who develop an immediate allergic reaction to pigment;however, spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to(initial one): Waive patch test and I agree to release the owner of this establishment,assistants,artists,and pigment manufacturer(s)from any and all liability related to allergic reaction or any other reaction to applied pigments. Take a 6-week patch test prior to the permanent cosmetic facial tattoo procedure.I agree to release the owner of this establishment,assistants,artists,and pigment manufacturer(s)from any and all liability related to allergic reaction or any other reaction to applied pigments. A. The Releasor agrees to accept full responsibility for the COLOR,SHAPE,AND THICKNESS of each and every procedure that the Releasor will have performed by the Releasee which is to include but not limited to the eyeliner,eyebrows,lips,scar camouflage, breast re-pigmentation,and/or beauty mark permanent cosmetic procedure(s). This document is Copyright protected by SoffapQD Inc. It may not be reproduced without the expressed written permission of Soffap(&Inc. Call 925 248-6301 or write to 550 N. Canyons Parkway,Livermore,CA 94551. All rights reserved. C)Copyright,2014 SofTap(&Inc. Seek legal advice before using this document.