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• Feverish infection/infectious illnesses yes❑ no❑ • HIV positive yes❑ no❑ • Skin anomalies in the treatment zone (warts,melanomas, etc.) yes❑ no❑ • Immune system disorders yes❑ no❑ • Epilepsy yes❑ no❑ • Chemotherapy or irradiation yes❑ no❑ • Surgery for a past 0.5 year yes❑ no❑ • Acute heart/cardiovascular problems yes❑ no❑ • Conjunctivitis yes❑ no❑ • Pregnancy or lactation yes❑ no❑ • Do you take any anticoagulant, blood thinning products? yes❑ no❑ • To your knowledge are you allergic or resistant to numbing products? yes❑ no❑ A"yes" answer does not indicate you are not an acceptable candidate for permanent cosmetics. It may indicate that based on any health conditions that can affect healing, it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it below. Also, please provide clarification for any"yes" answer you listed above. For the purpose of documentation, I am also content with the taking of"before" and "after" photographs of said procedure(s). These pictures will become the sole property of a Practitioner and may be used for advertising, promotional or educational purposes (If you do not want Jess to post your photos online, please let her know. But photos must mandatorily be taken for insurance purposes and to document the progress). I acknowledge and accept that the proposed procedure(s) all involve risk inherent in the procedure and the possibility of complications exists both during and following the procedure. Infection, misplaced pigment, migrating pigment, poor colour retention, or fever blisters are a few of the possible complications. I understand that if I decide to change the colour or shape after the initial application or in the future, that I may need additional session(s)to achieve the desired result and depth of colour. I understand that there will be NO refunds after treatment of this elective procedure(s). I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO MY SATISFACTION, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE FULLY REQUESTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL. I have read and understood the above information. Client Name Signature Date Practitioner Name Signature Date