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THE LUSH STUDIO - MICROBLADING <br /> INFORMED CONSENT, MEDICAL HISTORY & RELEASE FORM <br /> Check any condition(s) listed that applies to you: <br /> Diabetes / Epilepsy / Asthma / Fainting / Dizziness <br /> Heart Condition / Cardiac Valve Disease / Hemophilia / Blood Thinners <br /> Herpes / T.B. / Eczema, Psoriasis, or other skin conditions / Herpes <br /> Scarring/Keloiding / Pregnant/Nursing <br /> OTHER <br /> List ALL other medical issues/illnesses here: <br /> Do you have any other medical or skin conditions that may affect the outcome of your procedure? <br /> No Yes If yes, list all here: <br /> The information I have provided above is complete and true to the best of my knowledge. <br /> Signature: Date: <br />