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PERMANENT MAKE-UP INFORMED CON NT FORM FILE INFORMATION - PLE A4P PRINT CLEARLY W Follow up Name Date Address Email City/State/Zip Date of Birth Home Phone Work Phone Cell Phone In Case of Emergency Notify Phone How did you hear about this service GENERAL & MEDICAL INFORMATION- PLEASE PRINT CLEARLY Have you ever had historyof Herpes j"Xection at proposed procedure site? Yes_ NO_ Are you prescribed Antibiotics pnor`d surgery ? Yes_ NO_„ Are you pregnant? Yes_ Nos Any known allergies? Yes_No_ If so,to what? To Latex? Yes Noe To Lanolin? Yes_ No— Have you ever had a reaction to a skin care product? Yes . No_ If so,what? List all medications you are currently taking. Do you take ASPIRIN daily? Yes_ NO If so, How many mg/day. Present Illnesses? Illness History. Cardiac Valve disease? Yes No_„_,,, Do you have any blood disease like Hepatitis,HIV or AIDS? Yes_ No_._. Diabetes? Yes____No_ Do You have a Kelold condition? Yes_..,No— If so.where? Are you currently using exfoliators? (AHA or Retin-A) Yes— No— Herpes? Yes____, No_ Have you ever had cold sores on your lips? Yes—. No_ Hemophilia or bleeding disorder? Yes_ No Client Consent To Treat My Signature acknowledges that I have read and agree to consent this Permanent Make-Up procedure and any additional procedures that I may have in the future. * I(print) consent and authorize Barbara Nava to perform permanent make-up or other related skin care services on me. !..The nature and method of the proposed procedure have been explained to me as well as the usual risks inherent to the procedure and the possibility of complications resulting from the procedure. I fully understand there may be adverse side effects that may include,but are not limited to temporary minor bleeding, bruising, swelling and redness and that a healing period is normal and expected. I will follow after procedure care instructions made by Barbara Nava . I understand one touch-up is included with the procedure and that touch-ups cannot be made unless the area is healed. Fading of pigment may occur making an additional application necessary. I acknowledge that artistic advice related to color and shape has been provided,but that the ultimate decision was mine. I agree tllat Barbara Navas liability is limited to the cost of the procedure unless it is proven that she was negligent in her duties. I agree to binding arbitration to resolve any disputes. I have been advised that if I am prone to colli sores, Zovorax,prescribed by a physician should be taken prior to the procedure. I understand that cold sores are stress induced and not a result of improper techniques. I hold Barbara Nava harmless for any allergic reaction I may have to pigments. I understand that there is no guarantee for successful pigment removal,correction or camouflage procedures due to the many variables included. I understand only disposable equipment is used and risk of infection from the procedure is small,but the possibility cannot be precluded. —I accept,this risk and release Barbara Nava! from any and all liability related to the procedure,excepting instances of gross negligence. y I am over 18 years of age. w I will inform Barbara Nava' of any complications or concerns I may have as soon as they occur. Client/Patient Signature Date undtMand that ?SEMAn2al Mjk2 Mg Agftenj Rvjri nd mag need 12 h2 reggySh2d or r2dgn2 In .depending Qn individual skin Mel,skin aiementa ion.lifestyles:are.ect.