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If yes, please list: <br /> Are you pregnant or nursing? YES NO <br /> The above is complete and accurate to my medical history. <br /> CLIENT SIGNATURE: DATE: <br /> TOUCH-UP DATE: <br /> TOUCH-UP DATE: <br /> TOUCH-UP DATE: <br /> CONSENT TO PERMANENT MAKE-UP APPLICATION, RELEASE AND WAIVER OF ALL CLAIMS <br /> I acknowledge by signing this release that I have been given the full opportunity to ask any and <br /> all questions which 1 might have about obtaining permanent make-up from <br /> hereafter called "Technician" and that all of my questions have been <br /> answered to my full and total satisfaction. I specifically acknowledge that I have been advised of <br /> the matters set forth below and agree as <br /> follows: <br /> Initials at each line: <br /> I acknowledge that obtaining permanent make-up is my choice alone. The <br /> application of permanent make-up will result in a permanent change to my appearance, and <br /> that needles and inks will go into my skin. No representations have been made to me as to the <br /> ability to later restore the skin involved in permanent make-up to the original condition, and it <br /> is very costly to remove. <br /> I am not pregnant or nursing. I do not have any history of herpes infection at the <br /> proposed procedure site. I do not have epilepsy, diabetes, allergic reaction to latex or <br /> antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer <br /> from any heart conditions or take medications that thin the blood. <br /> If I suffer from hepatitis, or other risk factors for bloodborne pathogen exposure, or <br />