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Artist: Contact: <br /> Name: <br /> Home Address: <br /> No.&Street City State Zip <br /> Work Address: <br /> Na&street City State Zip <br /> Home Phone:( ) Work Phone: <br /> Employer.• Occupation: <br /> Are you now or have you been under the care of a physician within the last two years? <br /> If yes,please provide Physician's Name,address and phone number. <br /> Person to contact in an emergency: <br /> Name <br /> Address&Phone Na <br /> List all medications you are currently taking,including Retin A,Glycolic Acid and Acutane: <br /> List any drug,makeup,skin or food allergies (i.e.latex,soap or antibiotics: <br /> Have you recently undergone a skin peel. <br /> What products do you use for skin care? <br /> Do you have or have you had any of the following conditions (answer Yes or No): <br /> Abnormal Heart Condition Eve Surgery or Injuurryy <br /> Cold Sores Blepharojplasty (eyeEd surgery-) <br /> Herpes Simplex Visual Disturbances <br /> Hemophilia Cancer <br /> Hih or Low Blood Pressure Tumors/Growths/Cysts <br /> PrAonged Bleeding Chemotherapy/Radiation <br /> Circulatory Problems Are you pregnant? <br /> Epilepsy Hepatitis <br /> Diabetes Do you wear contact lenses? <br /> Fainting Spells/Dizziness Keloid condition <br /> Cataracts Cardiac Valve Disease? <br /> Glaucoma Eye Drops or Ocular Medicatons? <br /> Dry Fye Hyper-pigmentation? <br /> 'Corneal Abrasions Currtmttly taking aspirin/ibuprofen? <br /> When was your last eye exam? <br /> Examining Physician: <br /> Signature Date <br /> /Users/shaunafox/Desktop/2017 REVISED Consent Form(UPDATED)(2).docx Rev:12/5/2016 Page 5 of 8 <br />